However, it takes 10–21 days after infection before a 30–50% decrease in bone density allows an osseous lesion to be seen on conventional radiographs. Plain radiographs are the initial step in the radiological assessment of osteomyelitis. Only one of these patients had a lesion on the hip. A PubMed search using the search terms ‘cryptococcal osteomyelitis’ and ‘immunocompetent host’ yielded 22 results. Ī study of 44 patients aged 3–79 years found cryptococcal osteomyelitis predominantly involved the vertebrae, followed by the ribs/scapula, femur, humerus and skull. The most common underlying condition in these individuals was sarcoidosis, followed by tuberculosis, steroid treatment, lymphoma and leukaemia. Very few HIV-negative patients have been diagnosed with cryptococcal osteomyelitis. It is rare for cryptococcosis to manifest as osteomyelitis of the pelvis. Disseminated infections frequently involve the central nervous system and osseous lesions are uncommon (5–10%). After infected aerosolized particles are inhaled, the infection is either cleared or latent infection is established, perhaps in granulomas, with the lungs serving as the principal foci. Previously known as European blastomycosis, torulosis or Busse-Buschke disease, cryptococcosis is an opportunistic infection caused by either Cryptococcus neoformans, typically present in soil contaminated with avian excreta, or Cryptococcus gattii, which is found on trees, especially eucalyptus. CT revealed a 1.2×1.1 cm nodular lesion in the right upper lobe, ill-defined small centrilobular ground-glass nodules in the right lower lobe base, mediastinal adenopathies (some with calcification), and multiple discrete para-aortic, aortocaval and paracaval nodes suggesting the possibility of a granulomatous lesion ( Fig. CT of the chest was performed since cryptococcal osteomyelitis is rare in immunocompetent individuals without any pulmonary involvement. A serum cryptococcal antigen test was positive. The CD4 T-cell count was 975 cells/μl and the CD8 T-cell count was 967 cells/μl, well within the normal ranges. Tests for HIV, hepatitis B and C were negative. Microscopic examination of the biopsy sample revealed “non-viable bone spicules with focal necrosis, ill-defined granulomas & exudative inflammation with Cryptococcus, consistent with fungal osteomyelitis” ( Fig. The nucleic acid amplification test (NAAT) for tuberculosis and resistance to rifampicin assay (RIF) were negative. The sample was sent for culture and sensitivity testing. The patient subsequently underwent computed tomography (CT)-guided biopsy of the left ischium bone. MRI of the hip revealed hyper-intense areas in the left ischial tuberosity and inferior pubic ramus on STIR, and soft tissue oedema involving the pyriformis, external and internal obturator muscles, suggestive of osteomyelitis of the left ischial tuberosity ( Fig. The patient was advised to undergo magnetic resonance imaging (MRI) because of the prolonged pain. Laboratory work-up showed nothing significant. Other systemic examinations were also unremarkable. His vital signs including temperature, pulse rate, blood pressure, oxygen saturation and respiratory rate were within normal limits. On examination, the patient was well built and well-nourished with a BMI of 22.3 kg/m 2. There was no history of weight loss, difficulty breathing, bowel or bladder disturbance, intravenous drug use or high-risk sexual behaviour. Over the next 5 days he experienced nocturnal fever, which led him to seek medical advice. The pain started to radiate down the left posterior thigh and leg and intensified after 15 days, when the patient began to have trouble walking. He presented to a nearby physiotherapy clinic with intermittent pain and discomfort and received short wave diathermy and transcutaneous electrical nerve stimulation (TENS) on three separate occasions over 1 month with no relief of symptoms. He was from southern India and newly diagnosed with type 2 diabetes mellitus (HbA1c 6.8). A 42-year-old middle-class male solar power plant worker started to experience poorly localized low backache.
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