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Fungal and protozoa infections

Fungal and protozoal infections need to be considered in the differential of musculoskeletal presentations in areas of the world where these infections are endemic. 

South American blastomycosis also known as Paracoccidioidomycosis results from spores inhalation following exposure to contaminated soil in endemic area. Primary infections commonly involve the lungs, mainly in adult agricultural workers although secondary dissemination to other sites including bone may occur.  Spore penetration through injured skin is also described. Both immunocompetent and immunocompromised persons can be infected, but more severe disease occurs in the immunocompromised individuals.

  • A case (Fever and Arthritis 3) describes osseous blastomycosis in a healthy child living in endemic rural Brazil. This case illustrates the importance of considering blastomycosis in the differential diagnosis of bone pain and lesions for children and adolescents living or having travelled to an endemic area. Blastomycosis is endemic in Latin America. It is described, albeit rarely, in North America and Europe and in these cases, prior residence in Latin America was documented. 

Further information is available - Centre for Disease Control and Prevention 

Doria AS, Taylor GA: Bony involvement in paracoccidioidomycosis. Pediatric Radiology 1997, 27(1):67-69.

Visceral leishmaniasis is a systemic disease affecting the reticuloendothelial system, caused by protozoa of the genus Leishmania.  This infection affects dogs and humans and is transmitted from the bite of female sandflies. Over the last decade, the disease prevalence has increased five-fold mainly due to an expansion in global sandfly distribution associated with climate changes. 

A case (Fever and Systemic Features) describes a child with visceral leishmaniasis having presented with fever, cytopenia, autoantibodies and a presumptive diagnosis of connective tissue disease. Albeit rare, this is a diagnosis that needs to be considered with children and adolescents who live in endemic areas or have travelled to an endemic area. 

  • Leishmaniasis is endemic in many countries including North Africa, Central and South America, the Middle East, the Indian subcontinent and Southern Europe.
  • The main manifestations include muscle wasting, prolonged fever, weight loss, splenomegaly and pancytopenia. Musculoskeletal symptoms of myalgia and arthralgia accompanied by fever and systemic features raise suspicion of malignancy and infection: however once excluded, the differential diagnosis will consider multisystem diseases including connective tissue diseases and haemophagocytic lymphohistiocytosis. Consideration of leishmaniasis is important as the clinical scenario of suspected immunological / rheumatic disease may prompt systemic corticosteroid treatments to be given. This would clearly not be appropriate with visceral leishmaniasis infection.  
  • The association of haemophagocytic syndrome and visceral leishmaniasis is rarely found in childhood. It is an atypical presentation of a parasitic infection mimicking childhood-onset systemic lupus erythematosus and unspecific autoimmune phenomena. Prolonged fever and musculoskeletal complaints were the presenting features: the diagnosis needs to be considered for those living in, or having travelled to an endemic area. 

Further information is available from the Centre for Disease Control and Prevention 

Reference

Scalzone M, Ruggiero A, Mastrangelo S, Trombatore G, Ridola V, Maurizi P, Riccardi R: Hemophagocytic lymphohistiocytosis and visceral leishmaniasis in children: case report and systematic review of literature. Journal of infection in developing countries 2016, 10(1):103-108.

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