Fungal Infections of Bones and Joints

Fungi are an infrequent but clinically important cause of bone and joint infections. These infections are often indolent in onset and may masquerade as other disorders. Travel and immigration have affected the geographic localization of several important fungal infections, which may be seen in nonendemic areas. Although diagnosis may be assisted by clinical presentation and serologic and antigen testing, histologic examination and culture of infected tissue are critical. Rheumatologists should be particularly careful when treating atypical cases of subacute arthritis or tenosynovitis with local and systemic corticosteroids when infection with atypical pathogens, including fungi, has not been ruled out. New antifungal therapies have broadened the effective options, but choice of drugs, duration of treatment, and combined surgical débridement must be carefully considered to achieve optimal outcomes. Immunocompromise, including anti-rheumatic biologic therapies, may predispose to fungal infections, often resulting in more acute and widely disseminated disease. In general, screening and/or prophylactic therapy have not proven useful for patients on immunosuppressive therapy, so a high index of suspicion should be maintained when such patients present with an acute illness.