Osteomyelitis caused by Candida albicans is a rare invasive fungal infection, often associated with immunocompromised patients and chronic conditions such as diabetes mellitus, cardiovascular diseases, rheumatoid arthritis, cancer, and renal or hepatic disease, as well as prolonged antibiotic therapy and repeated surgical interventions. Descriptions involving the skull base are scarce. We report the case of a 54-year-old woman (S.S.N.R.), with diabetes, hypertension, and on dialysis, who presented with right otalgia for two months without response to multiple antibiotic regimens. Head CT showed right otomastoiditis and edema of the temporomandibular space. She underwent tympanomastoidectomy, exploratory tympanotomy, facial nerve decompression, and tympanoplasty with ossicular reconstruction, followed by empiric antibiotic therapy with meropenem and vancomycin for 42 days without clinical resolution. Culture of a skull base bone fragment isolated Candida albicans susceptible to amphotericin B, caspofungin, fluconazole, micafungin, and voriconazole. Histopathology of a skull base lesion fragment showed connective tissue associated with epithelial fragments with mild cytologic atypia, without criteria for malignancy. The literature reports that fewer than 5% of fungal osteomyelitis cases are caused by Candida spp. and emphasizes diagnostic difficulty, as early signs may mimic common bacterial infections. Systematic reviews recommend extensive surgical debridement associated with targeted antifungal therapy, starting with echinocandins and transitioning to azoles for at least six weeks, although protocols are largely based on case series and expert opinion. This report highlights the importance of suspecting fungal infection in patients with unsatisfactory therapeutic responses and risk factors, correlating bone tissue culture results, and tailoring antifungal therapy to prevent progression and severe complications such as intracranial extension and neurologic deficits.
Fonseca et al. (Sun,) studied this question.