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A budding surprise from the joint

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Reactivation of dormant infections is increasingly recognised with immunosuppression for rheumatic diseases. Septic arthritis from dimorphic fungi is exceedingly rare in non-endemic settings. We describe the first Australian case of Histoplasma capsulatum septic arthritis in a man of Laotian descent who was receiving treatment for seropositive rheumatoid arthritis.

Clinical record

A 78-year-old man of Laotian descent but resident in Australia for many years was referred in October 2010 with bilateral wrist extensor tenosynovitis, and a diagnosis of seropositive rheumatoid arthritis was made (cyclic citrullinated peptide antibody level, > 200 U/mL [reference interval, < 5 U/mL]; rheumatoid-factor negative). Although oral methotrexate initially improved disease control, he later had progressive disease involving his knees and ankles. Prednisone (5–15 mg daily) and leflunomide (10 mg daily) were added without much improvement, and he was considered for further immune modulation therapy. The patient’s background included tuberculous cervical lymphadenitis in 2009 (positive result of culture for Mycobacterium tuberculosis), treated with 12 months of standard quadruple therapy.

In March…