Fungal Osteomyelitis: A Systematic Review of Reported Cases

Abstract

Fungal osteomyelitis is considered a rare disease, and the published literature mainly comprises case reports, case series and narrative reviews. A systematic review was undertaken to provide a practice-based global perspective on this disease, focusing on epidemiology and treatment strategies. We searched MEDLINE, EMBASE and Cochrane Library between the 3rd and 8th of March 2023 using a predefined search string. We included studies with at least one patient with a diagnosis of fungal osteomyelitis published before the 1st of January 2023. We included all study designs except for reviews, and we excluded non-English languages and grey literature. After exclusion, 678 studies, mostly case reports, were included. Descriptive analysis was performed on 1072 patients. The most common aetiological agent was Aspergillus (26.5%), followed by Candida (20.7%) and Mucor (16.8%), and the bones most frequently involved were the vertebrae. We described the characteristics of patients divided by site of infection, and we found that diabetes mellitus, disseminated fungal infection, surgery and local lesion were major risk factors. We also successfully associated duration of treatment with outcome. We provided a general overview of this rare disease, and we highlighted the need for high-quality investigations on the subject.

Keywords: Aspergillus; Candida; Coccidioides; Crytpococcus; Mucormycosis; Scedoscporium; fungal osteomyelitis; fungal spondylodiscitis.

Figure 1

PRISMA flow chart for studies identification, screening and inclusion.

Figure 2

Histogram showing the year of publication (range = 1953–2022) frequency distribution for the 590 selected studies (A) and histogram showing the frequency distribution of the countries of origin of the patients, excluding countries contributing 3 or fewer patients (B).

Figure 3

Circular bar plots showing the frequency distribution of the aetiological agents among the selected studies (A), the aetiological agents among the patients (B), the site of infection among the selected studies (C) and the site of infection among the patients (D).

Figure 4

Bar plot showing the frequency distribution of antifungal treatment adopted in each study. Note that some studies included a combined treatment of two or more classes of antifungals.