Postoperatively 400 mg day−1 of VORI was continued for 4 months. Three months after cessation of VORI treatment (October 2003), ulcerous, inflamed skin lesion appeared on patient’s

upper leg. Again microbiological culture proved P. apiosperma as cause of infection. The isolate was again tested in vitro and had a HKI-272 mw MIC for VORI of 1 mg l−1. Extensive debridement was performed, since other case studies report only a successful cure when surgical excision of all infected tissues and antifungal therapy is combined.23,24 The debrided tissue was found by histological examination to contain fungal elements including conidia (Fig. 5). Therefore, antifungal therapy was restarted as combination of VORI (2 dd of 200 mg) and terbinafine (2 dd of 250 mg), as in vitro studies25 and previous cases reported favourable outcomes of Scedosporium infections with azole–terbinafine drug combinations.26–28 He was treated for 6 months after which he remained symptom free for a year until 2005 when he experienced a renewed infection (beside

bacteria no fungi were cultured) for which a re-amputation was necessary. The same surgical procedure was necessary twice in 2007, both times with negative fungal cultures. In 2008, the amputation wound was finally dry and closed. At follow-up in January 2011 the patient is asymptomatic and had experienced no recurrence since two years, but he is confined to a wheelchair because a prosthesis is technically not feasible due to the short stump and the poor condition of the soft tissues. To find more the best of our knowledge this case represents the first report of a PJI in an immunocompetent patient involving a Pseudallescheria/Scedosporium species. The source of infection was not identified. The patient had no conspicuous clinical history, beside a car accident one month before surgery. He neither aspirated water during the car accident, nor Aspartate suffered from deep wounds or other injuries, beside a whiplash. Therefore, injuries resulting from the car accident can be excluded as source of infection. More likely the patient was infected during the surgical procedure or he contaminated the

postoperative wound during his daily work as a cattle farmer. Wound contamination with animal dung might represent the most likely source of infection in this case. Up to now, Scedosporium-arthritis was always reported following a traumatic inoculation of Scedosporium-contaminated materials,13,18,29 but was never reported associated with a joint prosthesis. Scedosporium was four times earlier described as agent of postoperative infections around prostheses in immunocompromised patients. A double endobronchial prosthesis in a bilateral lung transplant recipient,6 an implantable cardioverter-defibrillator,7 and two cases of prosthetic valve endocarditis due to Scedosporium were reported.8,9 The immunocompetent patient in this case repetitively developed ulcerous skin lesions, fistula and pus-filled tissue pockets.