Fungal arthritis of native joints is an uncommon clinical entity, representing <1% of all septic arthritis cases ^[1]. Hip joint involvement is particularly rare and frequently misdiagnosed as bacterial septic arthritis or tuberculosis, especially in endemic regions ^[2,3,4,5,6]. Patients with chronic kidney disease (CKD) on long-term hemodialysis are predisposed to opportunistic infections due to immunosuppression, vascular access, and repeated interventions ^[3,4,7]. Prompt recognition and targeted management are essential to prevent progressive joint destruction and disability.

A 52-year-old male with CKD on maintenance hemodialysis for 5 years presented with gradually worsening left hip pain and reduced mobility over 18 months. Clinical examination revealed painful restriction of motion. Radiograph (Fig. 1) and magnetic resonance imaging showed advanced destructive arthritis of the hip. A two-stage surgical procedure was planned. In stage one (Fig.2), thorough debridement was performed, and an antibiotic-impregnated cement spacer was placed (Fig.3). Intra-operative tissue cultures grew Candida guilliermondii. The patient was treated with intravenous Caspofungin for six weeks, after which inflammatory markers normalised.

Figure 1: Pre-operative Radiograph demonstrating advanced destructive arthritis of left hip

Figure 2: Intra-operative pictures showing significant synovitis and effusion

Figure 3: Post-operative radiograph following stage-1 surgery demonstrating antibiotic cement spacer.

Stage two involved total hip replacement (Fig.4). The post-operative course was uneventful. At 12 months follow-up, the patient reported marked pain relief, improved range of motion, and independent ambulation.

Figure 4: Post-operative radiograph following stage 2 surgery showing well aligned THR.

Fungal arthritis accounts for a very small fraction of native joint infections ^[1,2]. Candida species are more commonly implicated in prosthetic joint infections than native joints ^[6,8]. Candida guilliermondii is a rare pathogen but has been reported in immunocompromised hosts, especially in those with CKD and on dialysis ^[7,9]. Diagnosis requires a high index of suspicion, as symptoms are often non-specific and may mimic bacterial or tubercular arthritis ^[2,10]. Imaging findings are inconclusive; culture of joint fluid or intraoperative tissue remains the gold standard ^[11]. Treatment typically involves a combination of surgical debridement and systemic antifungal therapy ^[8,12]. Staged surgical management, as in this case, ensures eradication of infection while enabling subsequent joint reconstruction. Two-stage revision arthroplasty has been reported with favourable outcomes in Candida prosthetic joint infections ^[6,12].

Native hip joint infection due to Candida guilliermondii is exceptionally rare, particularly in dialysis-dependent patients. This case highlights the importance of early suspicion, culture-based diagnosis, prolonged antifungal therapy, and staged surgical management for achieving favourable outcomes.

This case highlights

• To have a high index of suspicion of subacute/chronic infection ( Fungal / Koch’s) with atypical clinical and radiological presentation in immunocompromised patient.
• The importance of tissue culture to rule out fungal / tubercular / bacterial infection, especially in immunocompromised patient.