Ann Thorac Surg 2005;79:1057-1059
© 2005 The Society of Thoracic Surgeons
Case report
Recalcitrant Chest Wall Aspergillus Fumigatus Osteomyelitis After Coronary Artery Bypass Grafting: Successful Radical Surgical and Medical Management
Mohammed M. Elahi, MDa,
Amit Mitra, MD, FRCSa,
Julia Spears, MDa,
James B. McClurken, MD, FACSb,*
a Plastic Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
b Cardiac and Thoracic Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
Accepted for publication September 11, 2003.
* Address reprint requests to Dr McClurken, Division of Cardiac and Thoracic Surgery, Suite 300, Parkinson Pavillion, 3401 N Broad St, Temple University Hospital, Philadelphia, PA 19140, USA
mcclurjb{at}tuhs.temple.edu
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Abstract
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This report describes a 62-year-old male diabetic patient with persistent chest wall osteomyelitis that developed after repeat coronary artery bypass grafting. The chronic infection was localized to the right anterior chest wall and refractory to medical and surgical treatment including long-term antiobiotics, five separate intraoperative debridements, and reconstruction with vascularized omentum over a two-year period at outside institutions. Aggressive surgical debridement with flap reconstruction resulted in definitive management. The organism isolated from multiple intraoperative bone, cartilage, and tissue cultures yielded Aspergillus fumigatus; therapy with itraconazole was utilized for 6 months. Surgical management of osteomyelitis and costochondritis is reviewed accompanied by a literature review on this uncommon cause of chronic chest wall infection.
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Introduction
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Fungal osteomyelitis and costochondritis of the chest wall and mediastinum are challenging clinical conditions to manage once established. Immune compromise and long-term antibacterial therapy contribute to establishing invasive fungal infections in surgically traumatized susceptible tissue.
A report of a cluster of lethal Aspergillus aortitis after cardiac surgery attributed an outbreak to construction-initiated airborne contamination of the operating room [1]. Another form of an A. fumigatus infection is aspergillosis: pulmonary manifestations can take one of three forms; allergic tracheobronchitis, invasive necrotizing infection usually seen in severely ill or immune compromised patients, and the development of mycetoma in an area of previous pulmonary disease.
After localizing the focus of chronic infection, radical debridement of all involved bone, cartilage, and soft tissue along with culture-tailored antimicrobic therapy is usually required. Obliteration of dead space, skeletal stabilization if required, and vascularized tissue coverage of thoracic and mediastinal contents are necessary. Failure to achieve successful resolution and wound closure may be due to inadequate debridement, incomplete pathogen identification, and local tissue factors such as microvascular occlusive disease affecting the flaps. Alternative therapy may include maintenance of local drainage, antimicrobial therapy of indefinite duration [2], and hyperbaric oxygen.
The incidence of mediastinal and chest wall infection after cardiac surgery has been reported to range from 0.39% to 8.4% [3, 4]. Greater than 90% of osteomyelitis in this region have bacterial and mycobacterial causation, with staphylococcal species predominating. Fungal species are rare causes of chronic infection of the ribs and sternum but have been increasingly recognized as important pathogens in persistent cases. Osteomyelitis and costochondritis of the chest wall may arise from the spread from a contiguous pulmonary infection or by hematogenous dissemination [2].
A 62-year-old diabetic, hypertensive male with prior right-sided cerebrovascular accident and chronic obstructive pulmonary disease was seen in August 2002 with a complex history of persistent osteomyelitis with chronic drainage from the right anterior chest. He had initial coronary artery bypass grafting (CABG) in 1990 followed by repeat CABG in September 2000 with use of the right internal mammary artery at outside institutions. Two months later, a sternal wound infection developed in the patient. A 4-week course of antibiotics was unsuccessful. In December 2000, sternal wires were removed, the sternum was debrided, and the intent was apparently for secondary healing. Multiple cultures while on antibiotics were not revealing. Further local debridement with partial seventh rib resection was performed in April 2002 for persistent pain and induration. Again, the wound was left open and treated with a vacuum-assisted system. Pain and drainage persisted without any growth on bacterial, acid fast, and fungal studies.
A third debridement was performed in August 2001 with partial resection of the sternum and wider resection of ribs 6, 7, and 8. A chronically draining 5-cm x 8-cm area of induration persisted. The patient had a fourth debridement by different surgeons in October 2001; the defect was closed over the right inframammary region with omentum reinforced by bilateral pectoralis major flaps.
The patient then presented to us in July 2002 with chronic chest wall pain with drainage but an incision that appeared deceivingly benign (Fig 1). Magnetic resonance imaging revealed significant right inferior chest wall inflammation involving soft tissue, bone, and cartilage per infectious disease consultants. A combined cardiothoracic and plastic surgical approach consisted of radical debridement of ribs 7, 8, 9, and 10, along with resection of all granulation tissue and sinus tracts. The pleura was not entered and bleeding margins were used as endpoints for rib resection. Numerous soft tissue specimens of bone, cartilage, and granulation tissue were cultured. A laterally based myocutaneous flap was rotated cephalad and a medially baced triangular skin flap was rotated followed by split thickness skin grafting (Fig 2).
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Fig 1. Appearance of right anterior chest wall wound and draining sinus after five attempts at debridement and closure.
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Fig 2. Intraoperative view of intercostal flap closure of wound and split thickness grafting of donor site.
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Aspergillus fumigatus grew from three separate tissue specimens. Itraconazole 200 mg PO daily was used for 6 months per infectious disease consultants. No signs of pulmonary infection were seen on computed tomography. Healing was complete with a 3-week postoperative appearance seen (Fig 3). Surveillance has now been out to 12 months with no recurrence.
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Fig 3. Appearance of right anterior chest wall three weeks after successful debridement and defect reconstruction.
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Comment
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Aspergillus was first described as a cause of sternal osteomyelitis after open heart surgery in 1979 [3, 4]. Subsequent sporadic case reports have described its involvement in rib, vertebral, tibial, and pelvic osteomyelitis from postsurgical, direct extension from pulmonary foci, hematogenous, intravenous drug sources, and AIDS [5]. Commonly, patients have been misdiagnosed for several months to years and the clinical condition takes an indolent but persistent course.
At our institution, tissue specimens are sent for aerobic, anaerobic, fungal, and atypical cultures at the time of chest wall debridement. This is of particular importance in cases of recalcitrant wound infections. Radical debridement of chronically inflamed soft tissues, bone, and cartilage is performed. Although the fungal infection in this case may have represented a superinfection after long courses of antibiotics and debridement five times previously elsewhere, the tenets of successful treatment remain. Retention of small foci of osteomyelitis and costochondritis are, in our experience, the main reason for treatment failure. Costal cartilage is exceedingly vulnerable to infection, particularly when denuded of perichondrium and(or) devascularized with internal mammary artery use [6]. Aggressive resection with collaboration of thoracic and plastic surgeons should be performed with the assurance that well vascularized defect coverage usually can be achieved through reconstructive procedures.
Newer triazole antifungals, fluconazole, and itraconazole provide the option of treating a patient indefinitely with a systemically acting oral preparation that has minimal side effects [7].
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References
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- Sanche-Recalde A, Mate I, Merino JL, Simon RS, Sobrino JA. Aspergillus aortitis after cardiac surgery. J Am Coll Cardiol. 2003;41:152–156[Abstract/Free Full Text]
- Tang TJ, Janssen JL, van der Vlies CH, et al. Aspergillus osteomyelitis after liver transplantation: conservative or surgical treatment? Eur J Gastroenterol Hepatol. 2000;12:123–126[Medline]
- Miller JI, Nahai F. Repair of the dehisced median sternotomy incision. Surg Clin of North Am. 1989;69:1091–1098
- Bishara J, Gartman-Israel D, Weinberger M, et al. Osteomyelitis of the ribs in the antibiotic era. Scand J Infec Dis. 2000;32:222–223
- Kelly CA, Chetty MN. Primary sternal osteomyelitis. Thorax. 1985;40:872–873[Free Full Text]
- Tack KJ, Rhame FS, Brown B, et al. Aspergillus osteomyelitis report of four cases and review of the literature. Am J Med. 1982;73:295–300[Medline]
- Denning DW, Tucker RM, Hanson LH, et al. Itraconazole in opportunistic mycoses: cryptococcosis and aspergillosis. J Am Acad Dermatol. 1990;23:602–607[Medline]
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Abstract
Introduction
