title: Fungal periprosthetic joint infection following total elbow arthroplasty: a case report and review of the literature.
abstract: BACKGROUND
  With improving surgical techniques for total elbow arthroplasty clinical outcomes have improved and its utilization continues to increase. Despite these advances, complication rates remain as high as 24%. Of these complications periprosthetic joint infection is one of the most common and morbid. The rheumatoid elbow remains a leading indication for total elbow arthroplasty. Patients with this condition frequently require immunosuppressive therapy, which places them at higher risk of both typical and atypical infections.
  
  
  METHODS
  We present the case of a persistent, late-onset periprosthetic joint infection in a total elbow arthroplasty of a 64-year-old Caucasian woman with severe refractory rheumatoid arthritis. The offending pathogen, Aspergillus terreus, is previously unreported in the arthroplasty literature and grew concurrently with coagulase-negative staphylococcus. Eradication of the fungal and bacterial agents involved resection arthroplasty, serial debridement, and multiple courses of intravenous and oral antimicrobial therapy. Two attempts at reimplantation arthroplasty failed to eliminate the infection and our patient ultimately required definitive resection arthroplasty.
  
  
  CONCLUSIONS
  Arthroplasty in the rheumatoid elbow confers with it a high complication rate. Inflammatory disease and immunosuppressive drugs combined with the subcutaneous anatomy of the elbow contribute to the risk of infection. Fungal periprosthetic joint infection in the rheumatoid patient presents both diagnostic and therapeutic challenges. Fungal growth should always be treated and requires organism-specific antimicrobials in conjunction with surgical debridement. More literature is needed to determine the optimal treatment regimen for this devastating complication.
authors.affiliation: Orthopaedic Surgery Resident PGY-3, Section of Orthopedic Surgery, Department of Surgery, University of Calgary, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada. cakwong87@gmail.com.
authors.forename: Cory A
authors.initials: CA
authors.lastname: Kwong
authors.affiliation: Section of Orthopedic Surgery, Department of Surgery, University of Calgary, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
authors.forename: Shannon K T
authors.initials: SK
authors.lastname: Puloski
authors.affiliation: Department of Surgery, University of Calgary, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Hildebrand
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000150:complications; D057929:Arthroplasty, Replacement, Elbow / Q000009:adverse effects*; D001228:Aspergillosis / Q000628:therapy*; D001230:Aspergillus / Q000302:isolation & purification; D004551:Elbow Joint / Q000000981:diagnostic imaging / Q000601:surgery; D058569:Elbow Prosthesis / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000382:microbiology / Q000628:therapy*; D011859:Radiography; D012086:Reoperation
chemical_list: D000935:Antifungal Agents
keywords: Aspergillus terreus; Fungal; Infection; Periprosthetic joint infection; Resection arthroplasty; Revision; Rheumatoid arthritis; Total elbow arthroplasty