title: Clinical challenge: fatal mucormycotic osteomyelitis caused by Rhizopus microsporus despite aggressive multimodal treatment.
abstract: BACKGROUND
  Mucormycosis is an invasive mycotic disease caused by fungi in the zygomycetes class. Although ubiquitous in the environment, zygomycetes are rarely known to cause invasive disease in immunocompromised hosts with a high mortality even under aggressive antifungal and surgical therapy. Clinically, mucormycosis frequently affects the sinus occasionally showing pulmonary or cerebral involvement. However skeletal manifestation with Rhizopus microsporus (RM) osteomyelitis leading to emergency surgical proximal femoral resection with fatal outcome has not been described yet.
  
  
  METHODS
  We report the case of a 73-year-old male suffering from myelodysplastic syndrome with precedent bone marrow transplantation. Six months after transplantation he consulted our internal medicine department in a septic condition with a four week history of painful swelling of the right hip. Radiography, computed tomography and magnetic resonance imaging revealed multiple bone infarcts in both femurs. In the right femoral head, neck and trochanteric region a recent infarct showed massive secondary osteomyelitis, breaking through the medial cortex. Emergency surgical proximal femoral resection was performed due to extensive bone and soft tissue destruction. Microbiological and basic local alignment search tool (BLAST) analysis revealed RM. Amphotericin B and posaconazole treatment with septic revision surgery was performed. However the disease ran a rapid course and was fatal two months after hospital admission.
  
  
  CONCLUSIONS
  This alarming result with extensive RM osteomyelitis in the proximal femur of an immunocompromised patient may hopefully warn medical staff to perform early imaging and aggressive surgical supported multimodal treatment in similar cases.
authors.forename: Norbert
authors.initials: N
authors.lastname: Harrasser
authors.affiliation: Clinic of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str, 22, 81675 Munich, Germany. ingo.banke@mri.tum.de.
authors.forename: Ingo J
authors.initials: IJ
authors.lastname: Banke
authors.forename: Matthias
authors.initials: M
authors.lastname: Hauschild
authors.forename: Ulrich
authors.initials: U
authors.lastname: Lenze
authors.forename: Peter M
authors.initials: PM
authors.lastname: Prodinger
authors.forename: Andreas
authors.initials: A
authors.lastname: Toepfer
authors.forename: Christian
authors.initials: C
authors.lastname: Peschel
authors.forename: Rüdiger
authors.initials: R
authors.lastname: von Eisenhart-Rothe
authors.forename: Ingo
authors.initials: I
authors.lastname: Ringshausen
authors.forename: Mareike
authors.initials: M
authors.lastname: Verbeek
mesh_terms: D000368:Aged; D000666:Amphotericin B / Q000008:administration & dosage; D000935:Antifungal Agents / Q000008:administration & dosage; D016026:Bone Marrow Transplantation / Q000009:adverse effects; D003131:Combined Modality Therapy; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D009091:Mucormycosis / Q000188:drug therapy / Q000209:etiology / Q000382:microbiology* / Q000601:surgery; D010019:Osteomyelitis / Q000188:drug therapy / Q000382:microbiology* / Q000601:surgery; D012233:Rhizopus / Q000187:drug effects / Q000302:isolation & purification* / Q000502:physiology; D014230:Triazoles / Q000008:administration & dosage
chemical_list: D000935:Antifungal Agents; D014230:Triazoles; C101425:posaconazole; D000666:Amphotericin B