Rare case of prosthetic and non-prosthetic Candida arthritis of bilateral knee joints by Candida parapsilosis successfully treated with fluconazole: A diagnostic paradox.

Osteoarticular candidiasis is a rare entity with only 332 cases worldwide of which Candida arthritis accounts for 112 (33.7 %) cases. Candida parapsilosis accounts for only 11 % cases. This study reports a unique proven case of right-sided prosthetic Candida arthritis immediately followed by left-sided non-prosthetic Candida arthritis of bilateral knee joints by Candida parapsilosis. A 53 year old female presented with swelling, varus deformity and medial jointline tenderness in bilateral knees (right > left) since 20 days with X-Ray suggestive of severe osteoarthritis of bilateral knee joints. Right total knee arthroplasty was performed following which right knee showed bloody discharge on post-operative day 9. Right knee biopsy and aspirate revealed white, smooth, pasty colonies on culture which was identified as Candida parapsilosis via Vitek 2 Compact system. Intraoperative right knee tissue taken during tibial insert replacement of right knee also demonstrated Candida parapsilosis on culture. Left knee arthrotomy was performed in view of pus discharge from left knee (non-operative). Intraoperative left knee pus sample and left knee tissue also revealed Candida parapsilosis on culture. Blood culture was sterile but direct multiple intra-articular injections of methylprednisolone taken one month back turned out to be an important predisposing factor in the case. All antibiotics were stopped and patient was solely put on IV fluconazole for two weeks after which she showed miraculous symptomatic improvement.