Fungal Musculoskeletal Infections:

Comprehensive Approach to Proper Diagnosis

Marina C. Akuri, MD • Jenny T. Bencardino, MD • Júlia B. Peixoto, MD • Vitor N. Sato, MD • Lucas K. Miyahara, MD • Daisy T. Kase, MD
Adriana M. Dell’Aquila, MD, PhD • Adham do Amaral e Castro, MD, PhD • Artur R. C. Fernandes, MD, PhD • André Y. Aihara, MD, PhD
Author affiliations, funding, and conflicts of interest are listed at the end of this article.

Fungal musculoskeletal infections often have subacute or indolent manifestations, making it difficult to distinguish them
from other diseases and infections, given that they are relatively uncommon. Fungal infections occur by hematogenous
spread, direct inoculation, or contiguous extension and may be related to different risk factors, including immunosuppres-
sion and occupational activity. The infection can manifest in isolation in the musculoskeletal system or as part of a systemic
process. The fungi may be endemic to certain regions or may be found throughout the world, and this can help to narrow
the diagnosis of the etiologic agent. Infections such as candidiasis, cryptococcosis, aspergillosis, and mucormycosis are
often related to immunosuppression. On the other hand, histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, and
blastomycosis can occur in healthy patients in geographic areas where these infections are endemic. Furthermore, infections
can be classified on the basis of the site of infection in the body. Some subcutaneous infections that can have osteoarticular
involvement include mycetoma, sporotrichosis, and phaeohyphomycosis. Different fungi affect specific bones and joints
with greater prevalence. Imaging has a critical role in the evaluation of these diseases. Imaging findings include nonspecific
features such as osteomyelitis and arthritis, with bone destruction, osseous erosion, mixed lytic and sclerotic lesions, and
joint space narrowing. Multifocal osteomyelitis and chronic arthritis with joint effusion and synovial thickening may also
occur. Although imaging findings are often nonspecific, some fungal infections may show findings that aid in narrowing the
differential diagnosis, especially when they are associated with the patient’s clinical condition and history, the site of osteo-
articular involvement, and the geographic location.
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RadioGraphics 2024; 44(7):e230176
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Content Codes: MK, MR
Abbreviations: FDG = fluorine 18 fluorodeoxyglucose,
STIR = short-tau inversion-recovery
TEACHING POINTS
„ Musculoskeletal infections are often subacute or indolent at patient
presentation and can mimic other diseases such as neoplasia, bacterial
infections, and tuberculosis. Fungal osteoarticular infections can affect
bones, joints, muscles, ligaments, and tendons and can occur in isolation
or as part of a systemic infection when other organs are involved.
„ Diagnosis can be challenging, requiring a high degree of clinical suspi-
cion to consider fungal disease as a possibility. Imaging is fundamental
to early diagnosis, follow-up, and assessment of fungal musculoskeletal
infections, showing bone and soft-tissue involvement, the extent of the
infection, and complications and allowing differentiation from conditions
that mimic infection.
„ Regarding geographic distribution, some fungi can be found worldwide,
while others are usually found in endemic areas. Primary pathogens oc-
cur in relatively well-defined geographic locations, while opportunistic
fungi are ubiquitous.
„ Fungal diskitis osteomyelitis can mimic tuberculosis, with spared inter-
vertebral disks, multilevel involvement, and subligamentous spreading
of the abscess. Other imaging features include a focal paravertebral
soft-tissue abnormality and partial disk involvement, sometimes spar-
ing the intranuclear disk cleft.
„ Fungi are important to consider in the differential diagnosis of muscu-
loskeletal infections. Their presence on images can be nonspecific and
should always be considered when there is suspicion for musculoskele-
tal infectious involvement, especially if there is extensive bone destruc-
tion and/or an inflammatory process of soft tissue, with a relatively in-
dolent clinical picture.
Introduction
Fungi are uncommon causes of musculoskeletal infections
(1,2). Musculoskeletal infections are often subacute or indo-
lent at patient presentation and can mimic other diseases
such as neoplasia, bacterial infections, and tuberculosis
(2,3). Fungal osteoarticular infections can affect bones,
joints, muscles, ligaments, and tendons and can occur in
isolation or as part of a systemic infection when other organs
are involved (2). When such infections occur, they are often
destructive, and their severity is mainly associated with the
immune status of the host and the inherent pathogenicity of
the organism (2).
Spreading mechanisms of fungal infection are triggered
by direct inoculation due to trauma or surgical manipula-
tion, contiguous extension, or hematogenous dissemination
(1) (4,5). Direct inoculation can occur through trauma or con-
tamination of a traumatic injury with soil, intravenous drug
use, parenteral treatment, intra-articular injection, arthro-
centesis, implantation of a prosthesis, or exposure to contam-
inated surgical instrumentation (5,6).
Fungal conditions can be divided based on the site of in-
fection, the acquisition route, or the virulence of the fungus
(7). Based on the site of infection, mycoses are classified as su-
perficial, cutaneous, subcutaneous, or systemic (7). Superfi-
cial and cutaneous infections are not addressed in this article.
Subcutaneous infections usually spread contiguously from
an initial skin inoculation site, commonly after trauma (2).
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Akuri et al
They involve the skin and surrounding soft tissues, including
muscles and fascia (2). Systemic spread of subcutaneous in-
fections is rare (8). Systemic infections occur by means of dis-
semination of the pathogen through the hematogenous route
from a distant focus, occasionally with lymphatic involve-
ment (8). The first site involved is usually the respiratory tract
after inhalation of the agent, followed by dissemination to
other organs including the musculoskeletal system (8). Based
on the acquisition route, fungal infections can be classified as
endogenous or exogenous infections. Endogenous infections
occur by means of colonization of flora or reactivation of a
previous infection, while exogenous infections include air-
way, cutaneous, or percutaneous entry points (7). Based on
fungal virulence, primary endemic pathogens can cause dis-
ease in immunocompetent hosts, while opportunistic patho-
gens cause infection in immunocompromised patients (7).
Moreover, fungal infections are endemic in some regions and
sporadic in others (9).
Diagnosis can be challenging, requiring a high degree of
clinical suspicion to consider fungal disease as a possibility
(2). Imaging is fundamental to early diagnosis, follow-up,
and assessment of fungal musculoskeletal infections, show-
ing bone and soft-tissue involvement, the extent of the in-
fection, and complications and allowing differentiation from
conditions that mimic infection (1,10–12). Prolonged drug
treatment is usually necessary, sometimes requiring surgi-
cal intervention (1,2). This article reviews the main aspects of
fungal infections in the musculoskeletal system.
Epidemiology
Fungal bone infection is rare (4). However, the incidence of
invasive fungal infections has increased worldwide, probably
due to the increased number of patients at risk (4,5). Epidemi-
ologic characteristics differ among types of fungi (12).
Osteoarticular fungal infections can affect both immuno-
suppressed and immunocompetent individuals (1,2,4). Im-
munosuppression is a risk factor for some osteoarticular fun-
gal infections, and its causes include HIV infection and AIDS,
organ transplant, chemotherapy, chronic corticosteroid treat-
ment, diabetes, and autoimmune diseases (1,5,10). Some risk
factors can be related to specific types of fungal infection (4).
For example, candida osteomyelitis may be related to risk fac-
tors such as surgery (mainly abdominal), trauma, and use of
illicit intravenous drugs (4). In general, immunosuppressed
patients have a higher predisposition for complications from
both endemic and ubiquitous fungal diseases (13).
Regarding geographic distribution, some fungi can be found
worldwide, while others are endemic to specific areas. Prima-
ry pathogens occur in relatively well-defined geographic loca-
tions, while opportunistic fungi are ubiquitous (7).
Thus, fungal musculoskeletal infections can be divided
into endemic systemic infections, which are infections caused
by endemic fungi and can occur in healthy hosts; opportunis-
tic systemic infections, which occur in patients immunosup-
pressed by ubiquitous fungi; and subcutaneous infections, in
which the main infection site is the subcutaneous tissue. The
geographic distribution and endemic areas of each fungus are
represented in Figure 1.
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Figure 1. Geographic regions of endemic mycoses and areas with multiple cases reported.
Imaging Techniques
Imaging findings may be nonspecific, and the differential
diagnosis with other etiologic infections and inflammatory
arthropathies may be difficult, thus requiring clinical data,
epidemiologic information, biopsy, and culture for confir-
mation (2,3,14). Imaging modalities include radiography, US,
CT, MRI, and PET/CT.
Findings of osteomyelitis on radiographs and CT images
include bone destruction, osseous erosion, mixed lytic and
sclerotic lesions, and joint space narrowing (3,5). Osteomyeli-
tis may progress to marked bone destruction, causing defor-
mity (3). Although some agents may appear as a single lytic
lesion resembling a bone tumor, in cases of hematogenous
spread, involvement of multifocal noncontiguous bones and
joints may be seen (2). US findings in fungal infections, with
the exception of mycetoma, are nonspecific and include
chronic joint involvement, with joint effusion and synovial
thickening (5), tenosynovitis, bursitis and edema, and swell-
ing of the soft tissues, which can become hardened due to
chronicity (15,16).
MRI is the most sensitive modality in diagnosis of muscu-
loskeletal fungal infection and for detecting soft-tissue col-
lections (3). Imaging findings are generally nonspecific and
include bone marrow involvement with hypointensity on
T1-weighted MR images and hyperintense foci on T2-weight-
ed MR images, with enhancement on contrast-enhanced MR
images (3). Other findings include multifocal osteomyelitis
and chronic arthritis, with synovial thickening resembling os-
teoarticular tuberculosis (5). Some studies (1,10) have demon-
strated the potential role of fluorine 18 (18F) fluorodeoxyglu-
cose (FDG) PET/CT in fungal infections. FDG is a nonspecific
marker that accumulates at sites of infection, including fungal
disease, and has potential in initial diagnosis and follow-up of
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Akuri et al
patients with these infections. FDG PET/CT pinpoints the site
of infection and its extension and allows monitoring of the
disease activity and response to therapy (10)(Fig 2).
Imaging is also used to guide biopsy sampling, which is re-
quired to confirm the diagnosis of fungal infection. Biopsies
may be performed percutaneously (closed biopsy under im-
aging guidance) or surgically (open biopsy) (17). Biopsies can
be guided by CT, CT fluoroscopy, or in some cases, US. MRI is
not commonly used for guiding biopsies; however, informa-
tion obtained from MRI studies, such as bone and soft-tissue
involvement, can be used in planning the procedure, espe-
cially when the findings are correlated with those of CT (17).
At least three tissue samples must be obtained, and the bulk
of the specimens should be placed in various culture tubes (17).
For histologic specimens, 10% formalin is added; for cytolog-
ic and microbiologic specimens, saline is added or an empty
sterile container is used (17). Paraspinal fluid collections and
intradiskal fluid may not contain organisms, but if there are
any fluid collections, they must be aspirated and the aspirate
should be sent for culture in sterile containers (17).
Although the imaging findings of fungal infections, in gen-
eral, are relatively nonspecific for indolent infections, some
infections may show findings that aid in narrowing the differ-
ential diagnosis. Tables 1 and 2 show the most affected joint
and bone sites for each fungal infection.
Systemic Endemic Fungal Infection
Systemic endemic fungal infections are found in distinct geo-
graphic regions (9) and are frequently encountered through-
out Latin America (defined as countries in Central and South
America), where they have an important effect on public
health (18). Unlike most other fungal pathogens, which pri-
marily infect people with a compromised immune system,
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July 2024
the endemic fungi can act as primary pathogens and cause
infections in immunocompetent people (19). Diagnosis and
management of these infections are challenging, particular-
ly because of the variability of clinical presentation, the fas-
tidious and slow-growing nature of the pathogens, and the
paucity of diagnostic tests (20). The main endemic fungal in-
fections with musculoskeletal involvement in South, Central,
and North America are histoplasmosis, paracoccidioidomyco-
sis, coccidioidomycosis, and blastomycosis. Table 3 summa-
rizes epidemiologic data for these infections.
Histoplasmosis
Histoplasmosis is caused by Histoplasma capsulatum, which
is distributed worldwide, but particularly in the Americas,
although it can be found in parts of southern and eastern Eu-
rope, Africa, Asia, and Australia (9,18,20). In the United States,
it is the most frequent endemic mycosis, with the distribution
traditionally in the Mississippi and Ohio river valleys (2,13).
Histoplasma duboisii is endemic in Africa (5).
Histoplasma is found in soil containing large amounts of
bird droppings and bat guano (13,18). After inhalation of spores,
most patients are asymptomatic or manifest with an acute re-
spiratory illness that is usually self-limited in immunocompe-
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Akuri et al
Figure 2. Fungal olecranon bursitis in an
80-year-old man who presented with elbow
pain. Drainage was performed, and cultures
showed Fonsecaea species (chromoblastomyco-
sis). (A) FDG PET/CT image shows an FDG-avid
region overlying the olecranon (arrow). (B) FDG
PET/CT image after drainage and treatment with
voriconazole for 2 months shows reduced FDG
uptake as a sign of response to therapy (arrow)
(C) Color Doppler US image shows a complex
fluid collection in the olecranon bursa, with
intense peripheral hypervascularity (arrow).
(D) Coronal contrast-enhanced T1-weighted MR
image shows an encapsulated fluid collection
with thick peripheral enhancement in keeping
with olecranon bursitis (arrow).
tent patients. However, more severe or symptomatic infection
may occur, especially in more heavily exposed or immunocom-
promised individuals (13,20). H capsulatum has an affinity for
the reticuloendothelial system (3). It may spread to the skin,
oral mucosa, brain, liver, spleen, lymph nodes, adrenal glands,
bones, intestines, mediastinum, and pericardium (3,5,9).
Musculoskeletal involvement of histoplasmosis usually oc-
curs in patients with disseminated disease, frequently being
multifocal, resembling sarcoidosis and tuberculosis (2,9). Some
patients may also have cutaneous lesions, hepatomegaly, or
lymphadenopathy (1). Lung disease is rarely described during
the course of osteoarticular infection (1). Histoplasmosis mainly
causes osteomyelitis of the spine and long bones and septic ar-
thritis of the knees and wrists (2). A focal osteolytic lesion in the
diaphysis of a long bone with or without an associated periosteal
reaction can be detected in patients with chronic osteomyelitis
(1,5). Histoplasmosis can also result in wrist and hand tenosy-
novitis and carpal tunnel syndrome (Fig 3) (21). A case report
(5) of myositis in an immunocompromised patient describes
multiple painful nodules in the skeletal muscles. Systemic
treatment is recommended for disseminated disease for at
least 12 months; itraconazole is the antifungal agent of choice,
with amphotericin used for the first 2–6 weeks (2).
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Table 1: Main Sites of Infection for Each Fungus

Fungal Infection Vertebra Knee Foot and Ankle Lower Limbs Long Bones Pelvis and Hip
Histoplasmosis X X X
Paracoccodioidomycosis X
Coccidioidomycosis X X X X X
Blastomycosis X X X
Cryptococcosis X X X* X
Candidiasis X X X X X X
Aspergillosis X X
Sporotrichosis X X X X
Mycetoma X X X
Sources.—References 1, 2, 5, 6, 9, 24, 25, 35, 43.
* Lower limbs in cryptococcosis involve the tibia.

Table 2: Main Sites of Infection for Each Fungus

Clavicle, Scapula,
Fungal Infection Hand and Wrist Ribs Sternum and Shoulder Skull Elbow
Histoplasmosis X
Paracoccodioidomycosis X X X
Coccidioidomycosis X X
Blastomycosis
Cryptococcosis X X X
Candidiasis X X X
Aspergillosis X X
Sporotrichosis X X
Mycetoma X
Sources.—References 1, 2, 5, 6, 9, 24, 25, 35, 43.

Paracoccidiodomycosis skeletal involvement of the disease includes bone lesions, with

Paracoccidioidomycosis is a systemic granulomatous disease
caused by thermodimorphic fungi that currently encompass-
es two species: Paracoccidoides brasiliensis and Paracoccidoides
lutzii. This disease is found in South America, especially in
Brazil, Venezuela, Colombia, Ecuador, and Argentina, where
it is considered endemic (22–24). It typically infects individu-
als in rural or suburban environments (24).
Paracoccidioidomycosis can be classified as acute, subacute,
or chronic (22). The acute, subacute, or juvenile form (5%–25%
of cases) predominantly affects children, adolescents, and
young adults (22) and it is characterized by a fast progression,
with lymphadenopathy, gastrointestinal manifestations, hep-
atosplenomegaly, osteoarticular involvement, and cutaneous
lesions (22–23). The chronic or adult form (74%–96% of cases),
typically manifests in adults aged 30–60 years, predominant-
ly affecting the lungs (22,24). However, some cases of chronic
unifocal bone involvement have been reported (25). Musculo-
a prevalence of 2%–30% of cases (24, 25–27), and, more rarely,
the joints and muscles are involved (24,28,29).
The disease can affect any bone in the axial or appendicular
skeleton, but most frequently it affects long bones, clavicula,
ribs, scapulae, and sternum. On the long bones, lesions usual-
ly originate in the medullary cavity of the diaphysis and extend
to the metaphysis and epiphysis, which are the most affected
sites due to their greater vascularization. The bone lesions
have been described as well-defined osteolytic lesions without
marginal sclerosis and little or no periosteal reaction (Fig 4)
(24). On CT images, the presence of fine reactive osteosclerosis
in the margins can be identified (30). At MRI, the main finding
is osteomyelitis (31). Joint involvement most often occurs by
means of extension of epiphyseal bone lesions (30).
The treatment of choice is antifungal medication, mainly
itraconazole, cotrimoxazole, and amphotericin B (22). After
adequate treatment is initiated, bone lesions show slow and

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Table 3: Epidemiologic Data for Main Fungal Endemic Systemic Infections

Infection Agent Condition to Grow Endemic Areas Transmission

Histoplasmosis Histoplasma Range from tropical Worldwide, including parts of Inhalation of spores in soil or
capsulatum to temperate Central and South America, dust contaminated with bird
climates Africa, Asia, and Australia or bat excreta (eg, during cave
Ohio and Mississippi River exploration)
valleys
Paracoccidioidomy- Paracoccidioides Tropical and sub- South and Central America, Inhalation of spores; spores
cosis brasiliensis tropical regions especially Brazil convert to invasive yeasts in
the lungs and are assumed to
spread to other sites via the
blood and lymphatic systems
Coccidioidomycosis Coccidioides im- Warm and dry Southwestern desert of the Inhalation of spores; the dissemi-
mitis or Coccidi- climates of semi- United States, Mexico, and nated form appears by hema-
oides posadasii deserts Central and South America togenous spread

Blastomycosis Blastomyces Temperate climates Ohio and Mississippi River Inhalation of spores; fungi grow as
dermatitidis valleys, Northern Midwest, mold at ambient temperature
Upstate New York, southern in soil enriched with animal
Canada, Africa, India, and excreta and in moist, decaying,
Israel acidic organic material, often
near rivers
Sources.—References 5, 9, 13–16, 21, 23, 32–34.

Figure 3. Histoplasmosis in a 29-year-old man who presented with progressive pain and swelling of the wrist
and hand of 6 months’ duration and no history of lung disease. Cultures showed H capsulatum. (A) Radio-
graph of the hand shows focal soft-tissue swelling in the thenar region (arrow). (B) Static US image shows fluid
distention of the flexor tendon sheaths, outlining multiple internal hyperechoic rice bodies (*). (C) Coronal
short-tau inversion-recovery (STIR) MR image shows tenosynovitis with loculated fluid along the flexor tendon
sheaths (arrow) associated with hypointense layered rice bodies (*).

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Figure 4. Paracoccidioidomycosis in a 54-year-old man who was a frequent traveler, with a history
of recent weight loss and chronic neck pain. He presented with diffuse cutaneous nodules, dyspha-
gia, odynophagia, cough, fever, night sweats, and paresthesias and weakness in the upper limbs for 1
month. (A) Axial contrast-enhanced CT image shows diffuse lung involvement with innumerable bilat-
eral small parenchymal nodules in random distribution. (B, C) Axial contrast-enhanced CT images (mediastinal [B] and bone [C] windows) show
destructive lytic lesions (left arrow in B) involving the left scapula, with associated loculated complex joint articular and periarticular effusions
(* in B and C) and vertebral bodies at different thoracic levels (right arrow in B). (D) Axial contrast-enhanced CT image (mediastinal window)
also shows a destructive lytic rib lesion with an adjacent extraosseous complex fluid collection (arrow). (E) Follow-up sagittal CT reconstruction
image acquired after 2 years of treatment shows interval healing of the lytic lesions replaced by sclerotic reactions (arrowheads).

gradual change, marked by fibrosis and neo-osteogenesis, with
a coarse and dense trabecular appearance (Fig 4E) (25,26,30).
Coccidioidomycosis
Coccidioidomycosis, or valley fever, is the infection caused by
the dimorphic fungus Coccidioides immitis, which has a world-
wide distribution and is endemic in the arid areas of the South-
western United States, Mexico, and South America (32). Typ-
ically, transmission occurs through inhalation of aerosolized
spores or arthroconidia from the soil (32,33), with an estimated
incidence of 248 cases per 100 000 people according to the Ar-
izona Department of Health Services (33). The primary focus
of infection is the lungs. Nonspecific flulike symptoms develop
in only approximately 40% of patients, and the remainder of
patients are asymptomatic (14,32). The incidence of systemic
spread is still not clear, but it is estimated at 1%–5%, with at least
three risk factors associated with disseminated disease: ethnic-
ity (especially African or Pacific Island ancestry), sex (more in
male than female patients), and suppression of cell-mediated
immunity (14,32). The disseminated form can involve any or-
gan including the skin, lymph nodes, lungs, bones, kidneys,
and the central nervous system (14).
A musculoskeletal coccidioides infection can affect the
skeleton, joints, and soft tissues, typically in a multifocal
pattern involving multiple bones or joints (33). It can be as-
sociated with lung and cutaneous lesions (1). The axial skele-
ton, particularly the spine, ribs, pelvis, and skull, is the most
common site of infection (9,14), but all bones can be affect-
ed (14). Radiologic patterns vary, including well-demarcated
punched-out osteolytic lesions and lytic permeative patterns
with periosteal reaction and soft-tissue swelling (14). The
spine is the most common site of involvement, with the in-
fection typically starting in the vertebral body and extend-
ing to the periosteum and surrounding soft tissues, leading
to formation of a phlegmon or an abscess (14,33). The disease
can spread to several contiguous vertebral levels or appear as
skip lesions affecting nonconsecutive levels (14). Interverte-
bral disk spaces are usually spared (33). Vertebral body col-
lapse, when present, may be asymmetric, and involvement
of posterior elements is rare (33). In long tubular bones, coc-
cidioidomycosis occurs mainly in the metaphysis, and the phy-
seal plates cannot prevent the infection from spreading. Bone
protuberances such as the iliac and ischial spines, trochanters,
and tubercules are frequently affected (14).
Another form of disease is a self-limited migratory sterile
polyarthritis (“desert rheumatism”) that occurs as a hyper-
sensitivity syndrome in some cases of acute nondisseminat-
ed disease (9,14). Coccidioidal arthritis develops by means
of direct extension of an adjacent bone infection. The knees,
ankles (9,14), and wrists are the most commonly affected pe-
ripheral joints (2). Soft-tissue abscesses, tenosynovitis, and
septic bursitis are also possible manifestations (14). Treatment

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guidelines suggest initial therapy with amphotericin B, fol-
lowed by long-term fluconazole or itraconazole. Surgical inter-
vention depends on the presence of a neurologic deficit, per-
sistent instability, or intractable pain (2).
Blastomycosis
Blastomycosis is a disease caused by fungi in the genus Blasto-
myces dermatidis, a dimorphic fungus, which is endemic in the
upper Midwest United States and Canada (5,13,34). The preva-
lence of blastomycosis is 1:100 000 individuals in endemic re-
gions, reaching up to 40 times more prevalence in the hyper­
endemic regions, such as north and central Wisconsin (13).
After the lungs and skin, osteoarticular involvement is the
third most frequent site for blastomycosis (1). More than 90%
of clinical cases are pulmonary infections, although many
cases are asymptomatic. Hematologic dissemination occurs
in up to 25% of symptomatic patients, with primary sites of
dissemination including the skin (in up to 80% of individu-
als), musculoskeletal system (particularly the bones in up to
25%–60% of cases), central nervous system, and genitouri-
nary system (13,19,35).
Blastomycosis may affect almost any bone in the skeleton,
particularly the spine and lower limbs (5,35). Thoracic and
lumbar vertebrae (and the thoracolumbar junction) are the
most commonly involved bones, often with large paraverte-
bral abscesses, similar to tuberculosis (5,36). Imaging reveals
destruction and collapse of multiple vertebral bodies, with
noncontiguous vertebral involvement and spread through
the anterior longitudinal ligament (36). The vertebral disk
can be involved or can be relatively spared (5,36). In the long
bones, although there is no typical radiographic appearance
of blastomycosis osteomyelitis, lesions can be classified as
focal or diffuse. The focal pattern may have a sclerotic mar-
gin and expand slowly, generally with a periosteal reaction
in the long bones. The diffuse pattern has a more aggressive
appearance, with rapid bone destruction (ie, a moth-eaten
pattern) and vigorous periosteal reaction (5,35,37). Treatment
generally consists of amphotericin induction followed by
oral itraconazole (2). In more severe cases, with spinal canal
compromise, surgical intervention may be indicated (36).
Systemic Opportunistic Disease
Usually opportunistic fungi prefer habitats that are inde-
pendent from the host organism but can cause infections by
breaching the host’s immune defenses (38). The incidence
of invasive mycoses has been increasing significantly due to
opportunistic fungal pathogens (39). Aspergillus and Candida
species are the main organisms most frequently isolated from
immunocompromised patients. The other relevant etiologic
agents are Zygomycete, Cryptococcus species, Fusarium species,
and dematiaceous fungi (39). The opportunistic systemic fun-
gal infections addressed in this article are candidiasis, crypto-
coccosis, aspergillosis, and mucormycosis.
Osteoarticular Candida Infection
Osteoarticular candidiasis is caused most commonly by Candi-
da albicans, Candida glabrata, Candida parapsilosis, and Candida
tropicalis (38,40). Risk factors for osteoarticular candidiasis
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Akuri et al
include immunocompromised status (eg, neutropenia, use
of glucocorticoid therapy), antibiotic therapy, use of injected
drugs (38), surgical procedures, orthopedic devices or pros-
theses, trauma, or open wounds, as well as conditions that are
associated with candidemia, such as the use of central venous
catheters and total parenteral nutritional support (41,42). Re-
garding candidal arthritis, the main risk factor is disseminat-
ed candidiasis and its associated conditions and treatments
including hematologic malignancies, diabetes mellitus, solid
organ transplant, open wounds, and hemodialysis (40). The
most common mechanism of osteoarticular Candida infection
is hematogenous dissemination, followed by direct traumatic
inoculation (43). The most common site is the vertebrae (Fig 5),
followed by the femora, ribs, sternum, humeri (43), foot, ankle,
and tibia (6).
Arthritis manifests in 70% of patients as a monoarticular
infection, and the knee is the most frequently infected site, fol-
lowed by the hip and shoulder joints (1). Spinal involvement is
more common in the lumbar or thoracic spine (40). Candida
infection may be suspected when low-signal-intensity spinal
inflammatory masses on T2-weighted MR images and small
paraspinal abscesses are present in immunocompromised pa-
tients (44). Percutaneous closed guided biopsy or open biopsy
should be performed to establish a definitive diagnosis of os-
teomyelitis. Regarding candidal arthritis, a definitive diagnosis
requires needle aspiration, open biopsy, or arthroscopic surgery
for the acquisition of synovial fluid or tissue (1). The use of anti-
fungal agents for 6–12 months is the main treatment option (45).
Cryptococcosis
Cryptococcosis (ie, torulosis, European blastomycosis, or
Busse-Buschke disease) is a systemic mycosis caused by fun-
gi of the Cryptococcus neoformans complex, currently with two
species: C neoformans and Cryptococcus gattii. The former is
usually associated with opportunistic cryptococcosis, while
the latter is associated with the primary form of an immu-
nocompetent host, being endemic in tropical areas (46). The
most common sites of infection for cryptococcosis are the cen-
tral nervous system and the lungs (1). Skeletal involvement
has been reported in 5%–10% cases of cryptococcosis and is
usually secondary to disseminated disease (9). In some stud-
ies (5,9,46), investigators describe the lesions as restricted to
a single bone, and the most frequently involved sites are the
pelvis, vertebrae, skull ribs, clavicles, knees, and tibia, with
vertebral involvement occurring particularly in the dissemi-
nated forms of the disease. Vertebral lesions appear similar to
those of pyogenic osteomyelitis, with more frequent paraver-
tebral abscesses and extradural cryptococcal granulomas (9).
Radiography and CT show one or more osteolytic lesions, usu-
ally with no periosteal reaction, with minimal or no sclerosis
(9,46). In rare cases, musculoskeletal cryptococcosis infection
produces osteomyelitis or septic arthritis (2,46). In the case
of osteoarticular infection, infection in other sites should be
ruled out, including that in the central nervous system (1). To
our knowledge, there is no standard of care in the literature for
the treatment of osteoarticular lesions caused by Cryptococcus.
The reported cases were most often treated with a combina-
tion of antifungal drugs and surgical treatment (46).
8 radiographics.rsna.org
July 2024 Akuri et al

Figure 5. Candidiasis in a 38-year-old woman who underwent lumbar microdiskectomy and right laminectomy of the L5 vertebra. She
presented 5 days after surgery with low back pain associated with erythema, warmth, and hypersensitivity at the surgical site. Surgical
drainage was performed, and cultures were positive for C albicans. (A) Sagittal T1-weighted MR image shows marked hypointensity involv-
ing the intervertebral L5-S1 disk and adjacent vertebral endplates (arrow). (B) Sagittal STIR MR image shows increased signal intensity in
the L5-S1 disk and respective endplates (arrow), with an associated paraspinal fluid collection (*). (C) Axial contrast-enhanced T1-weight-
ed MR image shows enhancement of the L5-S1 intravertebral disk and an encapsulated fluid collection at the surgical site (arrow).

Osteoarticular Aspergillus Infection
Aspergillus is the second most common fungal group that
causes osteoarticular infections in immunocompromised
patients (1,47). Most affected patients have chronic granulo-
matous disease, followed by hematologic malignancies, im-
munosuppression therapy, neutropenia, and diabetes (48).
Orthopedic surgery, solid organ transplant, and hematologic
neoplasia are often observed in patients with aspergillus ar-
thritis (49). The most frequently infected bones in aspergillus
osteomyelitis are the vertebrae and the osseous structures of
the thoracic cavity including the ribs and sternum. The tibia is
the most infected long bone, and the knee is the most infected
joint (1). Aspergillus diskitis osteomyelitis should be consid-
ered in the differential diagnosis for immunocompromised
patients when multiple vertebral segments are involved, with
skip lesions or subligamentous spread (44). Other features
that may suggest aspergillus diskitis osteomyelitis are irreg-
ularities or a serrated appearance of the vertebral endplates
and subchondral hypointensity on T2-weighted MR images,
which is probably related to the presence of a paramagnetic
and ferromagnetic element within the fungi (50). Figure 6
shows a case of sacroiliac involvement. Definitive diagnosis
of osteoarticular aspergillus infection is usually established
with arthrocentesis, open surgery, or bone biopsy (47). Treat-
ment involves prolonged antifungal therapy that may be com-
bined with débridement or drainage (1).
Osteoarticular Mucormycosis
Osteoarticular mucormycosis remains a rare entity. The main
risk factor for its development is diabetic ketoacidosis (51). Oth-
er major risk factors include chemotherapy, stem cell trans-
plant, hematologic malignancies, solid organ transplant (52),
and HIV and AIDS (53).
Osteoarticular mucormycosis is an extremely aggressive dis-
ease usually manifesting with soft-tissue compromise and bone
destruction that occasionally is subject to amputation of an ex-
tremity. Osteomyelitis caused by Mucorales infection may affect
virtually any bone. Imaging findings are nonspecific (54,55),
and in a reported case of diskitis osteomyelitis (56), multiple
small erosions of the vertebral bodies were described. Bone de-
struction may be present, especially in the extremities (57).
Subcutaneous Infection
Subcutaneous fungal infections are a heterogeneous group of
mycoses that typically occur in tropical and subtropical coun-
tries after penetrating trauma to the skin (58). Sporotrichosis,
mycetoma, and chromoblastomycosis are the most frequent
subcutaneous mycoses (59). Chromoblastomycosis, phaeohy-
phomycosis, and mycetoma are part of the melanized or dema-
tiaceous fungi (60). Melanin is a virulence factor for these fungi
(58). This group of fungi is associated with a variety of diseases,
and many are soil organisms (58,61). Subcutaneous infections
may extend to deep planes and cause musculoskeletal infection
(60).
Sporotrichosis
Sporotrichosis, also known as farmer’s disease or “rose gar-
dener’s disease,” is most commonly caused by the fungus Spo-
rothrix schenckii, a common dimorphic fungus found in soil,
roses, and decaying wood (1,62). Infection occurs after skin

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July 2024
Figure 6. Aspergillosis in a 63-year-old woman who
presented with left hip pain and subacute low back
pain. (A) Sagittal T1-weighted MR image of the pelvis
shows hypointensity of the subchondral marrow
involving the left sacroiliac joint (arrow). (B) Coronal
STIR MR image shows bone marrow edema in the
left sacroiliac joint (arrow) with a periarticular fluid
collection (arrowhead). (C) Axial contrast-enhanced
T1-weighted MR image shows synovial enhancement,
sacroiliitis (arrow), and a fluid collection in the gluteus
maximus muscle (arrowhead).
trauma in rural areas in patients with occupational activities
such as agriculture, floriculture, and wood exploitation, par-
ticularly in tropical and subtropical zones, mainly in Japan,
India, Mexico, Brazil, Uruguay, Peru, and the United States.
Zoonotic transmission, particularly by cats, has also been de-
scribed (62). Sporotrichosis can be present in different clini-
cal forms. The most common form (75% of cases) is the lym-
phocutaneous form, in which there is involvement of the skin
and lymphatic system. Rarely does sporotrichosis manifest as
an extracutaneous form (62).
Volume 44 Number 7
Akuri et al
The osteoarticular form is the main extracutaneous form,
manifesting with arthritis or osteomyelitis (1,62). Arthritis is
most common, occurring in one or more joints (1). The knee
is the primary joint involved, followed by the hand, wrist,
metacarpophalangeal joint, elbow, foot, and ankle (1,9,55,63).
The affected joint may exhibit swelling, without other spe-
cific signs (1), or may manifest with multiple sinus tracts (5).
Isolated osteomyelitis occurs more commonly in long bones,
mainly in the lower limbs, flat bones, and hands, where it can
be associated with tenosynovitis (1). In addition, olecranon
and popliteal bursitis have also been described (9,64).
Imaging findings may be nonspecific and may include
“moth-eaten” or patchy radiolucencies without periosteal
reaction, juxta-articular bone destruction or erosion, joint
space narrowing, and osteopenia (Fig 7) (1,63). The lesions
are also described as sclerotic and proliferative (5). Although
the imaging findings of sporotrichosis are similar to those of
other fungal infections and tuberculosis, the involvement of
small joints of the hands and feet is characteristic of this fun-
gal disease (9).
Mycetoma
Mycetomas are chronic suppurative infections characterized
by swelling, nodular lesions on the skin with multiple sinus
tracts, and fistulization of granules (grains). The disease occurs
in the skin and subcutaneous tissue and can extend to deep tis-
sues such as muscles, bones, fascia, joints, and tendons (65).
Mycetomas can be caused by bacteria (actinomycetomas) or
fungi (eumycetomas). The most common bacteria are Nocardia
brasiliensis and Actinamadura maturee, and the main fungi in-
clude Madurella mycetomatis, Madurella grisea, and white fungi
(65). Mycetomas are more frequent in the “mycetoma belt,” an
endemic area encompassing tropical and subtropical countries
located between 15° south and 30° north latitude. This area
mainly includes regions in Africa (eg, Sudan, Somalia, Senegal,
Nigeria, Chad, and Niger), India, and America (eg, Mexico, Ven-
ezuela, and Brazil) (65), typically in rural areas (66). The lower
limbs are predominantly affected by the disease, with the feet
being involved in 50% of cases. Other commonly affected sites
include the ankles, knees, and hands (65,66). Actinomycetoma
affects joints earlier than does eumycetoma (11).
The radiographic findings include soft-tissue enlargement,
superficial nodules, bone alterations such as sclerotic or lytic
destruction, periosteal reaction, extrinsic cortical scalloping,
and disorganization of the foot bones (5,67,68). Radiographic
findings with a pattern of spreading were classified by Abd El
Bagi et al (67) in 2003. Because the spreading occurs contig-
uously, early bone involvement occurs mainly in the cortical
bone (69). CT early findings include periosteal elevation, cor-
tical erosions, cortical hyperostosis, and endosteal prolifera-
tion (Fig 8) (69). Later bone imaging findings include a coarse
trabecular pattern, sequestrum, and frank bone destruction
(69). Soft-tissue changes include an infiltrating mass with
moderate and diffuse enhancement after injection of con-
trast material (69). Muscles may be thickened or partially de-
stroyed (69).
At MRI, a specific finding referred to as “dot in circle” is iden-
tifiable. It is characterized by multiple small spherical lesions
10 radiographics.rsna.org
July 2024
that appear hyperintense on T2-weighted MR images, with a
surrounding area of low signal intensity (hypointense rim) as-
sociated with a central hypointense dot, visible on T2-weight-
ed, STIR, and contrast-enhanced T1-weighted fat-suppressed
MR images. The high-signal-intensity foci represent granu-
lomas interspersed with a low-signal-intensity matrix repre-
senting fibrosis, and the hypointense central foci seen in many
lesions represent grains or fungal balls (Figs 9, 10) (70,71). US
reveals hypoechogenic lesions with small hyperechogenic foci,
Volume 44 Number 7
Akuri et al
Figure 7. Sporotrichosis in a 68-year-old
woman who presented with pain, swelling,
and a purulent wound at the fourth right
finger for 6 months. The patient also had
an ulcer in the left lower limb for 1 year and
other disseminated lesions for 11 months.
(A) Photograph shows skin lesions on the
fourth finger. (B) Radiograph of the fourth
finger shows marked bone destruction of the
proximal phalanx (arrowhead), associated
with swelling and edema of the adjacent soft
tissues. (C, D) Coronal T1-weighted (C) and
STIR (D) MR images show erosive changes,
marrow replacement of the fourth proximal
phalanx, and an associated extraosseous
soft-tissue component (arrow). (E) Axial con-
trast-enhanced T1-weighted MR image shows
a peripherally enhancing fluid collection, with
adjacent synovitis and inflammatory signs
(arrowhead).
Figure 8. Mycetoma in a 47-year-old man
with ankle pain and swelling for 3 years that
was associated with purulent discharge. (A) Ax-
ial unenhanced CT image (bone window) shows
an expansile lesion on the lateral aspect of the
calcaneus (arrowhead), with cortical disruption,
bone erosion (arrow), and extraosseous exten-
sion (arrowhead). (B, C) Axial fat-suppressed
T2-weighted (B) and T1-weighted (C) MR imag-
es show an expansile lesion (arrowhead) with
well-defined margins on the lateral aspect of
the calcaneus, with cortical breakthrough and
extension to adjacent soft tissues.
which correspond to the grains (70). In eumycetoma, these le-
sions manifest as multiple acute hyperreflective echoes and
single or multiple nonechogenic cavities with thick walls, while
actinomycetoma shows similar findings but with smaller, ag-
gregated hyperreflective echoes mainly located at the bottom
of the cavities (66,72).
A deep tissue biopsy with histopathologic and immunohis-
tochemical analysis is performed to confirm the diagnosis (66).
Treatment depends on the type of infection: Actinomycetoma
11 radiographics.rsna.org
July 2024 Akuri et al

Figure 9. Mycetoma in two patients. (A) Long-axis fat-suppressed T2-weighted MR image in a 59-year-old man with probable
osteomyelitis shows multiple confluent hyperintense soft-tissue cystlike areas with central low-signal-intensity foci (ie, dot-in-
circle) lesions (arrowhead), located in the subcutaneous soft tissues of the fifth toe. (B) Short-axis fat-suppressed T2-weighted
MR image in the same patient shows a lack of osseous involvement (arrowhead). (C) Sagittal T2-weighted MR image in a 55-year-
old patient with a 3-year history of a palpable mass on the dorsum of the foot shows lesions (arrow) in soft tissues without reach-
ing the bone surface. (D) Long-axis contrast-enhanced T1-weighted MR image shows multiple nodules (arrow) along the dorsum
of the foot, with mild peripheral enhancement and the dot-in-circle sign.

Figure 10. Mycetoma in a 40-year-old male farmer who presented with a tumor along the plantar surface of the
foot that was associated with swelling and discharge (A) Contrast-enhanced fat-suppressed T1-weighted MR image
shows a rounded mass (arrow) in the plantar subcutaneous tissue, with multiple cystlike lesions and the dot-in-cir-
cle sign (arrowhead) involving the plantar fascia and midfoot bones. (B) Short-axis contrast-enhanced T1-weighted
MR image shows osteomyelitis in the fifth metatarsal head (arrow) with marrow replacement, cortical destruction,
and enhancement.

is typically treated with antibiotics or chemotherapy, while eu-
mycetoma is managed with antifungal drugs such as itracon-
azole and voriconazole, but recurrence rates are high (73).
Surgical intervention may be indicated, with amputation in
advanced cases (66).
Phaeohyphomycosis
Phaeohyphomycosis is an uncommon fungal infection
caused by a heterogeneous group of melanized fungi (1,60).
The incidence is higher in warmer climates and lower lati-
tudes (1). The fungus is found in soil, plants, vegetable de-
bris, and wood (48). The infection may spread to the bones
or joints (60). Immunosuppressed patients who have under-
Volume 44 Number 7
gone a transplant, those with HIV and/or AIDS, patients with
neuropenia, and individuals with autoimmune disease are
more vulnerable to osteoarticular involvement (1,59). Imag-
ing findings of phaeohyphomycosis are not specific (Figs 11,
12). Treatment includes prolonged antifungal therapy such as
amphotericin B and voriconazole and surgical interventions
such as débridement (1,60).
Differential Diagnosis
Imaging findings of fungal infections are nonspecific, and
the differential diagnosis should include pyogenic infections,
tuberculosis, neuroarthropathy, and other inflammatory ar-
thropathies. In the context of diskitis osteomyelitis, some
12 radiographics.rsna.org
July 2024 Akuri et al

Figure 11. Phaeohyphomycosis in a 54-year-old man who presented with os-

teomyelitis and arthritis of the right knee 3 years after an open traumatic injury.
(A) Radiograph shows joint space narrowing, marginal erosions in the lateral
femoral condyle and lateral tibial plateau, and juxta-articular decreased bone
density (arrow). (B, C) Coronal nonenhanced T1-weighted (B) and contrast-en-
hanced fat-suppressed T1-weighted (C) MR images show marrow replacement
and a focal intramedullary fluid collection (arrow in B), with an enhancing pe-
ripheral capsule (arrowhead in C) suggestive of an abscess. Culture of the fluid
was positive for Phialophora and Fusarium species.

Figure 12. Melanized fungi in a 58-year-old male construction worker

with a 2-year history of progressive edema and skin hyperpigmentation of
the third finger, with local hyperemia, pain, and pus drainage. (A) Coronal
STIR MR image shows a markedly hyperintense soft-tissue lesion along the
volar face of the third finger (arrow). (B) Sagittal T1-weighted MR image
shows involvement of the third proximal phalangeal base, with erosion of
the palmar cortex (arrowhead). (C) Axial contrast-enhanced fat-suppressed
T1-weighted MR image shows the lesion centered in the flexor mechanism,
involving the proximal aspect of the A2 pulley, with edema and thicken-
ing of the flexor tendon (arrowhead). Biopsy results showed spores and
hyphae of melanized fungi.

with early intervertebral disk involvement and compromise

imaging characteristics can aid in the etiologic differential
diagnosis. Pyogenic diskitis osteomyelitis most commonly in-
volves the lumbar spine, followed by the thoracic and cervical
spine, affecting a single vertebral segment, which includes
one intervertebral disk and two adjacent vertebral bodies,
of adjacent vertebral bodies. There is homogeneous enhance-
ment of the affected vertebral bodies and a poorly defined
paravertebral mass (74). Tuberculous diskitis osteomyelitis
more frequently affects the thoracic spine and less commonly
affects the lumbar spine. Large paravertebral abscesses with
thin and smooth walls may be present, with subligamentous
spread involving three or more vertebral levels, affecting mul-
tiple vertebrae or the entire vertebral body. Intervertebral
disks are relatively spared. There are focal areas of signal in-
tensity alteration on T1 and T2-weighted MR images and het-
erogeneous enhancement of vertebral bodies. Calcifications
can be visualized within the paravertebral abscesses on CT
images (74). Tuberculosis rarely affects the posterior elements
(ie, the pedicles) (Fig 13) (75). A feature that can also help in the
differential diagnosis with other spine infections is the ante-
rior meningovertebral ligament, a midvertebral ligament that
can be preserved in patients with an anterior epidural abscess
that originates from slow-growing infections and metastasis
but is typically involved in pyogenic infections (76).

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July 2024 Akuri et al

Figure 13. Tuberculosis in a 34-year-old man with low back pain for 9 months associated with a nocturnal fever that worsened in the past 3
months. (A) Axial contrast-enhanced T1-weighted MR image shows osteomyelitis of the L3 vertebral body (arrow) with formation of intra- and
paravertebral abscesses (arrowhead) extending to the left psoas muscle. (B) Sagittal STIR MR image shows spondylodiskitis at the level of
L3-L4 (arrow), with reactive bone marrow edema (arrowhead) extending to the L2 vertebral body. (C) Sagittal contrast-enhanced T1-weight-
ed MR image shows infectious arthritis (arrowhead) of the left costovertebral joint of T9. (D) Axial contrast-enhanced CT image (soft-tissue
window) shows a fluid collection that extends to the left psoas muscle with calcific foci (arrowhead). (E, F) Axial contrast-enhanced chest (E)
and abdominal (F) CT images show pulmonary micronodules with miliary distribution and a renal abscess (arrowhead in F), respectively,
also caused by a tuberculosis infection.

Clinical predictors of fungal diskitis osteomyelitis include
back pain for 10 weeks or longer, current antibiotic use for 1
week or more, and intravenous drug use (77). Fungal diskitis
osteomyelitis can mimic tuberculosis, with spared interverte-
bral disks, multilevel involvement, and subligamentous spread
of the abscess (3,74). Other imaging features include a focal
paravertebral soft-tissue abnormality and partial disk involve-
ment, sometimes sparing the intranuclear disk cleft (77).
Although there are no pathognomonic imaging findings
to differentiate between fungal diskitis osteomyelitis and
tuberculosis, the location of lesions and the development of
soft-tissue abscesses can be very useful. Blastomycosis and
tuberculosis have a predilection for the thoracolumbar junc-
tion, coccidioidomycosis for the thoracic spine, and crypto-
coccosis for the lumbar spine. As for paravertebral abscess-
es, blastomycosis and tuberculosis can form large abscesses
that may extend into the inguinal region and proximal thigh,
whereas blastomycosis has a greater predilection for forma-
tion of fistulas. Candida diskitis osteomyelitis may manifest
with low-signal-intensity spinal inflammatory masses on
T2-weighted MR images and small paraspinal abscesses
(44). Cryptococcosis often involves pedicles and laminae,
but formation of fistulas is not common. An element that
helps to differentiate blastomycosis from tuberculosis (both
having a predilection for the lumbar and thoracolumbar
junction and possibly forming paravertebral abscesses)
is involvement of posterior elements and extension to the
posterior aspect of the ribs, which are highly suggestive of
blastomycosis and rare in tuberculosis (36). In cases of As-
pergillus diskitis osteomyelitis, disks may be hypointense on
T2-weighted MR images (50). Table 4 (77,78) summarizes the
main clinical and imaging findings that aid in the differen-
tial diagnosis of fungal infections, tuberculosis, and pyogenic
diskitis osteomyelitis.
Other disorders that can mimic spinal infections include
spinal neuroarthropathy and SAPHO syndrome (74). Spinal
neuroarthropathy, or Charcot spine, is a rare condition that
results from the loss of deep sensation and proprioception
due to a preexisting neurologic condition, leading to progres-
sive osseous and ligamentous injury in response to repeated
trauma. It most commonly occurs at the thoracolumbar, lum-
bosacral junction, and lumbar spine. It may involve one or
more vertebral segments. Imaging findings include vertebral
endplate and facet erosions, soft-tissue masses or fluid collec-
tions containing bone debris, osseous fragments, an altered
articular contour with incongruity of the intervertebral joint,
listhesis, intervertebral gas, and involvement of both anterior
and posterior elements (74,79).

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July 2024 Akuri et al

Table 4: Main Clinical and Imaging Findings of Fungal, Tuberculosis, and Acute Pyogenic Diskitis Osteomyelitis

Finding Fungal Tuberculosis Pyogenic

Imaging
Soft tissue Focal paravertebral soft-tissue Large and well-defined paraspinal Diffuse paravertebral soft-tissue
abnormality. abscess abnormality
Disk involvement Partial disk and endplate involve- Early stages may spare the disk space, Diffuse disk involvement
ment with only body involvement
Spinal involvement Thoracic and lumbar Thoracic spine Lumbar > thoracic > cervical
Skip lesions spine
Clinical
Inflammatory markers Usually normal Usually normal Increased
Symptoms Long-standing back pain (> 10 Systemic symptoms from other Acute back pain (<10 weeks)
weeks) systems
Other Current antibiotic use for >1 week ... Invasive instrumentation
Sources.—References 77, 79.

Figure 14. Rice bodies in a 47-year-old male farmer who presented with swelling in the dorsal region of the right wrist for 3 years. On physical
examination, there was a palpable abnormality with a soft consistency and not adhered to deep planes. (A) Radiograph shows an attenuating
soft-tissue prominence in the dorsal wrist (arrowhead). (B, C) Sagittal (B) and axial (C) fluid-sensitive MR images show a large complex fluid col-
lection in the dorsal wrist outlining rice bodies and communicating with the sixth extensor compartment (arrows). (D) Macroscopic photograph
of the surgical resection specimen shows that the culture was consistent with filamentous fungi.

SAPHO is an acronym that means synovitis, acne, pustu-
losis, hyperostosis, and osteitis (74). It affects the spine in ap-
proximately one-third of patients. The findings on MR images
are a focal or diffuse bone marrow signal intensity abnormal-
ity, endplate irregularities, paravertebral soft-tissue hyperin-
tensity at T2-weighted MRI, disk space narrowing, and fluid-
like signal intensity in the intervertebral disks, with contrast
enhancement (74).
Rice Bodies
Rice bodies occur in patients with chronic inflammation or
infections affecting joints or bursae (80). The pathogenesis is
uncertain, and it occurs in response to synovial inflammation.
Some authors (80) believe that they may arise from microin-
farcted synovium released into the joint, encased by fibrin depo-
sition, while others believe that they are formed independently
of synovial elements and exhibit progressive enlargement due
to fibrin aggregation. The differential diagnosis of inflammato-
ry conditions associated with formation of rice bodies includes
rheumatoid arthritis, tuberculosis, nontuberculous mycobacte-
rial arthritis, seronegative inflamammatory arthritis (81), and
fungal infections (80). Rice bodies can be detected on US and
MR images. However, if these rice bodies are small, they can
be misclassified as soft-tissue masses, debris, or viscous flu-
id in the bursae (81). Rice bodies are slightly hyperintense on
T2-weighted MR images and isointense to muscle on T1-weight-
ed MR images (Fig 14) (81).
Conclusion
Fungi are important to consider in the differential diagnosis
of musculoskeletal infections. Their presence on images can
be nonspecific and should always be considered when there

Volume 44 Number 7 15 radiographics.rsna.org

July 2024
is suspicion for musculoskeletal infectious involvement, espe-
cially if there is extensive bone destruction and/or an inflam-
matory process of soft tissue, with a relatively indolent clinical
picture.
For the diagnosis of fungal infections, it is important to
associate the site of infection and the clinical and occupa-
tional history, immunosuppression status, geographic loca-
tion, history of travel to endemic areas, and place of origin
for the immigrant population.
Author affiliations.—From the Department of Diagnostic Imaging, Escola Pau-
lista de Medicina, Universidade Federal de São Paulo, Napoleão de Barros
Street, 800 Vila Clementino, São Paulo, SP, Brazil 04024-002 (M.C.A., J.B.P.,
V.N.S., L.K.M., D.T.K., A.d.A.e.C., A.R.C.F., A.Y.A.); Department of Radiology,
Hospital das Clínicas da Faculdade de Medicina de Marília, Marília, São Pau-
lo, Brazil (M.C.A.); Department of Radiology, Montefiore Medical Center, The
University Hospital for Albert Einstein College of Medicine, Bronx, NY (J.T.B.);
Department of Diagnostic Imaging, Laboratório Delboni, DASA, São Paulo,
Brazil (J.B.P., V.N.S., L.K.M., D.T.K., A.Y.A.); Department of Radiology, Hospi-
tal do Coração, HCor and Teleimagem, São Paulo, Brazil (V.N.S.); Department
of Infectious Diseases, Universidade Federal de São Paulo, São Paulo, Brazil
(A.M.D.); Hospital Israelita Albert Einstein, São Paulo, Brazil (A.d.A.e.C.); and
Department of Radiology, Grupo de Radiologia e Diagnóstico por Imagem–
Rede D’Or, São Paulo, Brazil (A.R.C.F.). Presented as an education exhibit at
the 2022 RSNA Annual Meeting. Received June 22, 2023; revision requested
August 17 and received October 2; accepted October 17. Address correspon-
dence to M.C.A. (email: marina.akuri@gmail.com).
Current address: A.M.D. Hospital do Servidor Público Estadual, São Paulo, Brazil.
Acknowledgments.—The authors would like to thank Akemi Osawa, MD, for
for providing Figure 2, and Luiz Ferreira Alves, MSc, for the commissioned
illustrations.
Disclosures of conflicts of interest.—All authors, the editor, and the reviewers
have disclosed no relevant relationships.
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