title: Severe osteomyelitis caused by Myceliophthora thermophila after a pitchfork injury.
abstract: BACKGROUND
  Traumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively.
  
  
  METHODS
  A 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. Ultimately the primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels.
  
  
  CONCLUSIONS
  Unusual pathogens should be sought following traumatic farm injuries. Pharmacokinetic studies may be of critical importance when utilizing antifungal therapy with agents for which little information exists regarding drug metabolism in children.
authors.affiliation: Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, USA. ldestino@mcw.edu
authors.forename: Lauren
authors.initials: L
authors.lastname: Destino
authors.forename: Deanna A
authors.initials: DA
authors.lastname: Sutton
authors.forename: Anna L
authors.initials: AL
authors.lastname: Helon
authors.forename: Peter L
authors.initials: PL
authors.lastname: Havens
authors.forename: John G
authors.initials: JG
authors.lastname: Thometz
authors.forename: Rodney E
authors.initials: RE
authors.lastname: Willoughby
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Chusid
mesh_terms: D002675:Child, Preschool; D006801:Humans; D007718:Knee Injuries / Q000150:complications*; D008297:Male; D003904:Mitosporic Fungi / Q000302:isolation & purification*; D009181:Mycoses / Q000209:etiology*; D010019:Osteomyelitis / Q000209:etiology*; D011743:Pyrimidines / Q000627:therapeutic use; D014230:Triazoles / Q000627:therapeutic use; D065819:Voriconazole
chemical_list: D011743:Pyrimidines; D014230:Triazoles; D065819:Voriconazole