Case Report of Aspergillus Osteomyelitis of the Ribs in an Immunocompetent Patient
A 45-year-old lady presented with a history of right upper abdominal pain for six months. The pain worsened on deep inspiration and on applying pressure over the chest wall. It had been progressively worsening in severity. She gave a history of loss of appetite and loss of weight of approximately five kilograms during this period. There was no history of cough, fever or trauma. She gave a history of diabetes mellitus for five years, which was adequately controlled with oral hypoglycemic agents.\nOn examination, she had tenderness over her right upper abdomen. She had no underlying organomegaly, bony tenderness or lung findings. Investigations were normal, except an elevated ESR and CRP. Imaging studies, including chest radiograph, abdomen ultrasound and a bone scan were inconclusive. She was asked to follow-up after two months.\nShe presented again after six months with increased pain over the right upper quadrant. On examination, she was found to have a tender swelling on the right ninth and tenth ribs, measuring 3 × 2 cm each. With a tender swelling, and elevated inflammatory markers, a diagnosis of Osteomyelitis involving the ribs was made, and she underwent a computed tomography (CT) scan to confirm the same.\nCT of the chest and abdomen revealed a swelling over the lower end of the ninth and tenth ribs, associated with thickening of the underlying pleura, and necrosis of adjoining ribs and costochondral junctions. A screening ultrasound showed an 8cc collection with surrounding necrosis, which was aspirated under guidance. The histopathology report showed areas of necrosis on histology, with a lymphohistiocytic inflammatory infiltrate []. The aspirates were also sent for cultures, which grew Aspergillus fumigatus after two weeks of incubation []. This report was unexpected, as the patient did not have any traditional risk factors for Aspergillosis. She had diabetes mellitus, which was well controlled, without evidence of any complications.\nShe underwent surgical debridement, and was initiated on Voriconazole. She showed clinical improvement after the same