Mucormicosis after Anterior Cruciate Ligament (ACL) Reconstruction
Authors: Lapera Miguel , Gigante Facundo , Zabala Manuel Perez , Adjigogovic Esteban , Sylvester Francisco , Moirano Juan Manuel Torres , Rodriguez Emanuel Fedun 
Published: December 2018

We hereby present a case of a 23 year old male patient with an Anterior Cruciate Ligament (ACL) reconstruction with autologous hamstrings graft and fixation with Peek implants.

He attended our service 25 days after surgery with intense and persistent knee pain, periarticular effusion, edema, increased local temperature and poor wound drainage. The most striking symptom was the persistence of pain that did not yield with opioid analgesics.

Upon suspicion of infection, a routine lab study was performed. Serial blood cultures, X-Rays, CT, and knee MRI were taken.

The lab results showed leukocytosis with a 16,500 count, in predominance of Neutrophils 76.8%., and ESR increase, with negative blood cultures.

The decided procedure was to perform knee arthrocentesis and bacteriological and histochemical study with germ typification.

Fungal infection was suspected and specific study was requested with an Anatomopatologist. Examination with special histochemical technique, GROCCOTT, PAS and GIEMSA was performed, showing numerous fungal elements (thick and branched hyphae). Morphological findings are linked to Rhizopus infection (Mucormycosis)

NECROTIZING MYOCTIC ACUTE OSTEOMYELITIS.

Surgical treatment: Radical debridement with removal of surgical material. Arthrotomy and enlarged synovectomy in the suprapatellar recess. We proceeded to carve a window on the anterior distal femur of 6 x 4 cm with wide curettage and cavity filling with cement beads impregnated in Amphotericin. Closed drain for 48 Hs.

The Department of Infectious Diseases proceeded to perform parenteral treatment with Amphotericin B EV 1 mg / kg for 6 weeks (After 4 rotated Amphotericin B Liposomal because of nephrotoxicity). Postoperative control with MRI, CT and Lab. Biopsy 45 days after surgery. Negative bone culture and biopsy under direct vision with the presence of Anatomopatologist in the operating room with removal of cement beads with Amphotericin. The diaphysis of the femur is covered only with aponeurotic tissue, without bone grafts. For 4 months he proceeded to walk with crutches without load bearing.

At 12 months, lab control, without abnormalities, knee without effusion, slight deficit of flexion and extension, stable, with negative semiology, anterior drawer and pivot shift tests were negative and complementary studies of RNM and X-Rays only showed femoral diaphysis with bone rarefaction and secondary infection.

Bacteriological and laboratory without particularity considering the clinical picture in a definitive high way.

CONCLUSION:

Mucormycosis is a serious infection caused by fungi of the order Mucorales, of which the most important family is that of the Mucoraceae, which includes the genera Rhizopus, Mucor and Absidia. Low incidence infection, but with a high rate of morbidity and mortality. It is vital to make an early diagnosis, for which one has to maintain a high rate of clinical suspicion, this being the most fulminant mycotic disease in human beings. Our purpose is to present a case with very particular characteristics, which differ both in the clinical presentation and in the first lab results with the typical bacterial infection of the ACL postoperative knee.