Fungal arthritis: A challenging clinical entity

Table 1 Differential diagnosis for fungal arthritis

No.	Diagnosis
1	Bacterial arthritis
2	Tubercular arthritis
3	Sarcoidosis
4	Ewing’s sarcoma
5	Osteogenic sarcoma
6	Langerhans cell histiocytosis
7	Malignant metastasis

Table 2 Risk factors for specific fungal infections

Fungal infections	Risk factors
Candida spp.	Immunosuppression
	Chemotherapy
	Recent surgery
	Uncontrolled diabetes
	Corticosteroids
	Broad spectrum antibiotics
	Intravenous drug abuse
	Indwelling central venous catheters
	Hemodialysis
	Multiple site colonization
Aspergillus spp.	Neutropenia
	Chronic granulomatous disease
	Post-organ transplant
Coccidioides immitis	Uncontrolled diabetes
	Immunosuppression
	Advanced age
	HIV
Histoplasma capsulatum	HIV
	Advanced age
	Post-organ transplant
	Corticosteroids
	Immunosuppression

HIV: Human immunodeficiency virus.

Table 3 Therapeutic options for fungal arthritis

Antifungal drugs	Indication/pathogen	Dosage
Fluconazole	Candidiasis	400 mg (6 mg/kg) daily (IV/PO)
	Histoplasmosis
	Blastomycosis
	Coccidioides
	Cryptococcus
Voriconazole	Aspergillus	4-6 mg/kg BD; 200 mg BD (IV/PO)
	Candidiasis
	Coccidioides
	Blastomycosis
	Cryptococcus
	Histoplasmosis
Itraconazole	Aspergillus	100-400 mg/d (PO)
	Sporothrix
	Candidiasis
	Coccidioides
	Histoplasmosis
	Cryptococcus
	Blastomycosis
Ketoconazole	Blastomycosis (mild to moderate cases)	200-400 mg OD (PO)
	Coccidioides
	Cryptococcus
	Histoplasmosis
Liposomal amphotericin B	Candida species (except C. lusitaniae)	3-5 mg/kg/d (IV)
	Cryptococcus
	Aspergillus
	Coccidioides
	Histoplasmosis
	Sporothrix
Echinocandins: Caspofungin, anidulafungin, micafungin	Candidiasis (fungicidal)	Caspofungin: 70 mg on day 1 followed by 50 mg OD (IV); anidulafungin: 200 mg on day 1 followed by 100 mg OD (IV); micafungin: 100 mg OD (IV)
	Aspergillus (fungistatic)
5-Flucytosine	Cryptococcus	100 mg/kg/d divided q 6 h (PO)
	Candida

IV: Intravenous; PO: Per os (oral administration).