title: Diagnostic difficulty identifyingApophysomyces trapeziformisseptic arthritis in a patient with multiple myeloma.
abstract: BACKGROUND
  Mucormycosis is a rare fungal infection, but can cause substantial morbidity and mortality in both immunocompromised and immunocompetent patients.Apophysomycesis a mucormycetes species ubiquitous in nature, particularly in soil, decaying wood and other organic matter.Apophysomycesis known to cause cutaneous fungal infections, particularly after penetrating trauma. Septic arthritis is a rare clinical manifestation.
  
  
  METHODS
  We describe a case ofApophysomyces trapeziformiscausing septic arthritis of the knee of a patient with multiple myeloma. He was treated multiple times for bacterial septic arthritis with minimal improvement. Surgical tissue specimens finally grew mucoraceous mould, and DNA sequencing and morphological assessment of spores identified the mould asA. trapeziformis. The patient was treated with amphotericin B and posaconazole, but ultimately required an above-the-knee amputation for definitive treatment.
  
  
  CONCLUSIONS
  This case illustrates the need to evaluate for fungal infection in a persistent septic arthritis that is culture negative and refractory to empiric antibiotics, particularly in an immunocompromised individual. It also shows the importance of a thorough social history and adequate tissue specimens for culture.
authors.affiliation: Duke University Medical Center, 2100 Erwin Road, Durham, NC 27710, USA; Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA.
authors.forename: J Bradford
authors.initials: JB
authors.lastname: Bertumen
authors.affiliation: Duke University Medical Center , 2100 Erwin Road, Durham, NC 27710 , USA.
authors.forename: Wiley A
authors.initials: WA
authors.lastname: Schell
authors.affiliation: Durham VA Medical Center , 508 Fulton Street, Durham, NC 27705 , USA.
authors.forename: Maria
authors.initials: M
authors.lastname: Joyce
authors.affiliation: Durham VA Medical Center , 508 Fulton Street, Durham, NC 27705 , USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Alley
authors.affiliation: Duke University Medical Center, 2100 Erwin Road, Durham, NC 27710, USA; Durham VA Medical Center, 508 Fulton Street, Durham, NC 27705, USA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Woods
keywords: Apophysomyces; amputation; methenamine silver staining; mould; mucormycosis; septic arthritis