prosthetic joint infections ( pji ) are a serious complication associated with total knee replacement ( tka).1 fungal pji is a rare occurrence with few cases reported.123456 phelan et al . reported the first case of candidal pji in 1979.3 
 candida albicans is the most commonly isolated fungus.3 to the best of our knowledge , this is the first fungal pji reported from india , with candida tropicalis being the causative organism .
a 62 year old hypertensive non diabetic female presented with pain , swelling in the left knee and difficulty in walking in the left knee for the last 6 weeks .
a 15 cm vertical midline surgical scar healed by primary intention of the initial tka was present on anterior aspect of knee .
radiologically , there was osteolysis over the anterior femoral cortex , posterior femoral condyles and under the tibial base plate [ figure 1 ] .
complete hematological study and urine microscopy revealed no significant abnormality besides elevated erythrocyte sedimentation rate ( esr ) ( 75 mm at 1 hour ) and c - reactive protein ( crp ) ( 84 mg / l ) .
anteroposterior ( a ) and lateral radiographs ( b ) of knee joint showing osteolysis around femoral and tibial components .
tka was done 2 years ago knee joint aspiration was carried out under sterile conditions .
characteristics of the aspirate were 5 ml fluid , cloudy with low viscosity , white blood cell count was 15,000/cubic mm , with 68% polymorphonuclear leucocytes .
gram staining was negative , but 10% koh mount , done to rule out fungal infection as a standard hospital protocol , was positive suggesting a fungal infection . a decision to perform 1 stage of revision tka
was taken after consultation with the patient and her family . in consultation with infectious disease specialist
there was turbid synovial fluid , granulation tissue , implant loosening and adherent cement synovial fluid and tissue was sent for culture and sensitivity studies .
implant removal , debridement and antibiotic ( vancomycin ) plus antifungal ( amphotericin b ) impregnated cement spacer insertion was done [ figure 2 ] .
medical therapy included intravenous fluconazole 400 mg od for 6 weeks followed by oral fluconazole 400 mg bd for 12 weeks .
sabouraud dextrose agar and the rapid api 20 microtube system were used for identification of species .
peroperative clinical photographs showing first stage of revision total knee replacement , after implant ( a ) removal and cement spacer inserted ( b ) anteroposterior radiograph of the knee joint showing cement spacer patient was followed up at weekly intervals and after 20 weeks , the esr ( 23 mm at 1 hour ) and crp ( 6.3
postoperative period was uneventful and patient was discharged on oral fluconazole 400 mg bd for 10 weeks .
peroperative clinical photograph showing second stage of revision total knee replacement with final implants the surgical wound healed adequately and after physiotherapy , a painless range of motion of 10 - 90 with a stable knee was obtained .
patient maintained status quo until last followup 24 months after 2 stage of revision surgery [ figure 5 ] .
anteroposterior ( a ) and lateral ( b ) photographs of knee joint at 24 months followup showing implant in situ
fungal pji is known to occur in patients who are immunocompromised , have a underlying systemic illness or prolonged use of antibiotics.12345 despite this almost half the cases occur in patients without any identifiable risk factor.3 our patient had no identifiable risk factor .
c.albicans is the most common cause for fungal pji reported in english literature.12345678910 most of the reported cases , do not have systemic fungal disease.4 wu and hsu reported a patient with preoperative cutaneous candidiasis who developed candidal pji.10 no primary source of candidal infection was identified in our case .
there is very minimal probability of being implanted during the primary surgery ( the primary tka was over 2 years and symptoms are 6 weeks old ) .
late infections probably are hematogenous ; however , a definitive answer can not be given .
debridement with successful retention of the implants and suppressive antifungal therapy has been reported.4678 in few initial reports , surgeons performed debridement and resection arthroplasty alone , but this led to poor functional outcomes.3 delayed reimplantation offers the best chance to a successful functional outcome.123 we followed the same principle and performed a two stage revision arthroplasty .
one in vitro study on fungal biofilm has shown c.albicans producing quantitatively more biofilm than candida parapsilosis , candida glabrata and c. tropicalis .
these films have rapidly developed resistance to fluconazole.11 the optimal time to reimplantation has been debated.3 hwang et al .
have performed reimplantation at an average of 9.5 weeks.1 it has been recommended that in cases of pji with unusual or virulent organisms , the period between resection and reimplantation should be prolonged.3 after keeping patient on an extended course of antifungal therapy in consultation with infectious disease specialist , we performed a delayed reimplantation at 20 weeks .
we ensured that the esr , crp was normalized ; repeat aspiration was negative prior to reimplantation surgery .
amphotericin b is the gold standard , but is nephrotoxic and may not be useful for long term administration.310 fluconazole has demonstrated fewer side effects and can be used long term in patients .
successful treatment with fluconazole as the sole antifungal agent has been reported.367 a high bio - availability , extended half - life , absence of serious side effect and high concentration in joint fluid make fluconazole an excellent choice.10 our choice was fluconazole for the above mentioned reasons .
we followed the recommendations of infectious disease society of america and gave fluconazole in a combination of parenteral and oral formulation for a total period of 30 weeks [ table 1].123710 the cement spacer was loaded with amphotericin b , based on previous literature , for local action , but we do not have any analysis of the elution rate or the concentration it achieved in the joint . at present , there is no consensus on the type , dose or efficacy of antifungal used in cement spacers.12310 further research is required in this area . to conclude based on our experience and review of literature ,
we say that fungal pji , though rare , is a serious complication and is more difficult to manage than bacterial pji .
resection arthroplasty with antifungal therapy followed by delayed reimplantation offers the best possible result . despite this , further modalities of treatment including options during 1 stage of revision tka , the choice and total duration of antifungal therapy and time of reimplantation should be explored .
 fungal prosthetic joint infection after total knee arthroplasty ( tka ) is a rare complication . 
 lacunae exist in the management of this complication . 
 62 year old lady presented with pain and swelling in left knee and was diagnosed as candida tropicalis fungal infection after tka . 
 she underwent debridement , resection arthroplasty and antifungal plus antibiotic loaded cement spacer insertion , antifungal therapy with fluconazole followed by delayed revision tka and further fluconazole therapy . 
 total duration of fluconazole therapy was 30 weeks . at 2 year followup 
 , she has pain less range of motion of 10-90 and there is no evidence of recurrence of infection . 
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