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Fungal granuloma of proximal fibula: a very rare case report.

CASE REPORT: A 50 year old otherwise healthy male presented to the orthopaedic OPD with history of pain and swelling of approximately 4 months duration over proximal aspect of right upper leg laterally. Pain went on increasing and swelling gradually progressed to attain size of 3 x 4 cm. The patient denied any history of recent trauma to the extremity and reported no respiratory or systemic illness preceding the leg pain. He reported no fever, chills, or other constitutional symptoms and had recently screened negative for the human immunodeficiency virus (HIV).

PHYSICAL EXAMINATION: revealed that the patient was afebrile and that the vital signs were within normal limits .Examination of the right knee joint revealed swelling laterally over fibular head, 3 x 4 cm. in dimension, globular sized, tender, which was hard in consistency. Swelling was not addherent to skin and was immobile. Patient had full range of motion at knee joint without distal neurovascular deficit. Provisional diagnosis of case was aneurysmal bone cyst or giant cell tumour.

Routine blood investigation was normal. X-ray (fig-2a) showed a oval lytic expansile lesion at proximal fibula in epiphyseo-metaphyseal region with cortical thinning and narrow zone of transition in mature skeleton. MRI (fig. 1) showed an aggressive neoplastic lesion with cortical breech and large soft tissue component with invasion of lateral tibial plateau with significant soft tissue edema suggestive of GCT or clear cell chondrosarcoma. FNAC--s/o inflammatory cells and no neoplastic cells were identified.

Decided to excise the tumour, during excisional biopsy (Fig. 2b) an incision was taken over lateral aspect of upper leg. Intraoperative findings were of a mass with a rough surface and blackish scattered circular areas over whole of the mass .Then whole mass was excised enblock, very small part of tibial condyle was found involved and was excised, hemostasis was achieved and wound closed meticulously over drain.. The excised mass was sent for Histopathology and cytology examination (Fig. 3a and 3b) which showed large fungal balls surrounded by chronic granulomatous infiltrate of inflammatory cells with foreign body giant cells. No neoplastic lesion seen s/o fungal granulomatous lesion, thus led to diagnosis of fungal infection of head of fibula. Post-operative antibiotics and antifungal agents were given, dressing was checked on day five and sutures were removed on day fifteen.

Histopathology and Cytology Examination (fig. 3a, 3b): Which showed large fungal balls surrounded by chronic granulomatous infiltrate of inflammatory cells with foreign body giant cells.

DISCUSSION: Fungal granuloma of bone has been reported very very rarely in literature.(1,2,3)

Occasional infections of bone and joint, pathologically infectious granulomas, are caused by pathogenic fungi. They include blastomycosis, cryptococcosis, coccidial granuloma, actinomycosis, mycetoma, aspergilosis, mucormycosis. (4,5,6) These infections can present as joint effusion, arthritis, osteolytic lesions and osteomyelitis. (7) Large tubular bones are less commonly involved, the common areas of fungal involvement are brain and lungs. Presentation may be asymptomatic, acute or chronic pain, diffuse swelling or in form of sinuses or ulcers. (8) Because of their comparative rarity and resemblance, clinically and roentgenographically, to more common infections, they are readily overlooked. (4) Even on culture, the report is frequently "staphylococci" or "no growth." Repeated animal inoculation is sometimes required. Many times granulomatous fungal infection presenting as lytic lesion on radiograph may mimic bone tumours such as aneurysmal bone cyst, enchondroma or a giant cell tumour (2,3,9,10) and diagnosis frequently comes as a surprise by recognition of the organism by histopathological examination.

CONCLUSION: A high index of suspicion is required to make an early diagnosis of the fungal infections. The text also emphasizes the importance of including endemic fungal infections in the differential diagnosis of bone lesions. Fungal granuloma of bone may mimic a malignant condition.

DOI: 10.14260/jemds/2014/2634

REFERENCES:

(1.) Brijbala arora et al primary mycetoma of patella .ijo. 1979;13:24.

(2.) The Journal of Bone and Joint Surgery 4 May 2011: case report of 33 year old man presenting with wrist fungal granuloma.

(3.) Fungal infection by Paracoccidiodes brasiliensis micking bone tumour: Pediatric Blood Cancer, Volume 50, Issue6 pages 1284-1286 June 2008

(4.) Ray A. Carter infectious granuloma of bones and joints, with Special Reference to Coccidioidal Granuloma. Radiology; 1934(7), 23: 1-16.

(5.) NEUROLOGY INDIA: Invasive rhino-cerebral fungal granuloma; Muralimohan Seivam, Anil Pande, Vasudevan M Chakravarthy, Ravi Ramamurthi, Year: 2010 | Volume: 58 | Issue: 2 | Page: 270-276.

(6.) Rakesh singh, multiple osseeous involvement in case of disseminated cryptococcosis .ijo .2010;44 (3): 22.

(7.) Jang gyu cha et al candida albicans osteomyelitis of cervical spine. Skeletal radiol. 2008; 37:347350.

(8.) Lucas morretti et al radiological findings of osteoarticular infection in paracoccidiomycosis skeletal. Radiol. 2011; 18 may.

(9.) J. I. HUANG Coccidioidomycosis Fungal Infection in the Hand Mimicking a Metacarpal Enchondroma .J Hand Surg Eur.2000;1 25:475-477.

(10.) Clues to recognition of fungal origin of lytic skeletal lesions. I Hershkovitz, B M Rothschild, O Dutour, C Greenwald; Am J Phys Anthropol 1998 May;106 (1):47-60 9590524 Cit:9.

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Eknath D. Pawar [1], Saurabh Agrawal [2], Atul Patil [3], Gaurav Jain [4]

AUTHORS:

[1.] Eknath D. Pawar

[2.] Saurabh Agrawal

[3.] Atul Patil

[4.] Gaurav Jain

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor and HOD, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India.

[2.] Assistant Professor, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India.

[3.] Assistant Professor, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India.

[3.] Resident, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Eknath D. Pawar, Plot No. 107, F-1, Anatdarshan Apartment, Behind Varadganesh Mandir, Samarthnagar, Aurangabad--431001,

Maharashtra, India.

E-mail: drpawared2003@yahoo.co.in

Date of Submission: 28/03/2014.

Date of Peer Review: 29/03/2014.

Date of Acceptance: 11/04/2014.

Date of Publishing: 19/05/2014.
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Title Annotation:CASE REPORT
Author:Pawar, Eknath D.; Agrawal, Saurabh; Patil, Atul; Jain, Gaurav
Publication:Journal of Evolution of Medical and Dental Sciences
Date:May 19, 2014
Words:982
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