Mycetoma is most frequently encountered among males between 20-50 years living in countries along the equator. The prevalence is mostly seen in Mexico, Venezuela, Somalia, Senegal, Yemen, Sudan, and India. Inoculation of the organism after trauma is the predominant mode of infection, which is perhaps one of the reasons why the condition is more common among barefoot-walking populations [1] [2] [3]. Peasants and agriculture workers are at a particular risk for acquiring mycetoma, making occupational factors important in the pathogenesis [3]. A painless, firm mass containing numerous communicating nodules and abscesses is the typical lesion of mycetoma [1] [3] [4]. The feet are affected in the majority of cases, while hands and the trunk are other potential sites [3]. Nodular communication through the development of fistulas results in the release of a syrup-like purulent or seropurulent discharge that contains grains formed by the causative agent [5]. In some patients, a prolonged infection can lead to dissemination of pathogens into the skeletal system and the systemic circulation, causing bacteremia or even life-threatening sepsis [2]. The clinical course of mycetoma (also know as Madura's foot, named after the Indian endemic region of Madura) is rapid and amputation may be frequently indicated due to the extreme disfiguring of the distal extremities by nodular breakdown [2].

• Fever

  She had no fever and C-reactive protein was 120 mg/l. Magnetic resonance imaging (MRI) confirmed the destruction of tarsus bones with a tibia extension. [ncbi.nlm.nih.gov]

  Infection of the Salivary and Lacrimal Glands 65 10 Deep Neck Infections 73 PART III 77 11 Conjunctivitis 79 12 Keratitis 87 Keratitis Isolates 19932006 88 13 Iritis 97 14 Retinitis 103 15 Endophthalmitis 109 16 Periocular Infections 117 PART IV 121 17 Fever [books.google.es]

  We report a rare case of a 40-year-old male with a left foot plantar swelling of 4 months duration with no discharging sinuses, fever, and pain. There was no history of trauma or barefoot walking. [jocr.co.in]

• Lymphadenopathy

  Abstract A 13-year-old girl presented with multiple painless purulent ulcers with raised borders on the medial aspect of the sole of her right foot associated with inguinal lymphadenopathy for the past 4 years. [ncbi.nlm.nih.gov]

  21 Cellulitis and Erysipelas 151 Necrotizing Fasciitis 157 23 Human and Animal Bites 161 24 Lice Scabies and Myiasis 167 25 Superficial Fungal Diseases of the Hair Skin and Nails 173 Figure 2510 Method for 179 26 Mycetoma Madura Foot 181 27 Fever and Lymphadenopathy [books.google.es]

  (Fig. 1) General examination was unremarkable with no lymphadenopathy or other soft tissue masses. Though the clinical picture was characteristic, differential diagnoses of chronic bacterial osteomyelitis, botryomycosis were also considered. [faoj.org]

  There was no lymphadenopathy. There was no history of fever, discharging sinuses, or pain. There was no history of trauma or barefoot walking. [jocr.co.in]

• Pseudotumor

  We describe the case of a 51-year-old renal transplant recipient who presented with a large pseudotumoral foot lesion necessitating complete surgical excision of the lesion. Cultures and molecular diagnosis confirmed Phaeoacremonium fuscum. [ncbi.nlm.nih.gov]

  Pseudotumors of bone. Fr. Madura mycose. Ger: Madurafug. Sp: Pie de Madura. Definition Madura foot is, strictly, only one form of mycetoma: a true eumycetoma localized to the foot. [isradiology.org]

  The cervical CT injected ( Figure 2 ) found a pseudotumoral inflammatory attack in contact with the right submaxillary gland, extended to the pharyngolarynx and thyroid damage, with lysis of the thyroid cartilage. [medcraveonline.com]

• Recurrent Infection

  For fungal mycetoma, amputations and recurrent infections are common. Prevention & Control Mycetoma is not a notifiable disease (a disease required by law to be reported) and a global surveillance system is still being developed. [who.int]

  In general actinomycetoma responds very well to antibiotic treatment only, while eumycetoma needs a combination of antifungal treatment and surgery and even then recurrent infections are common. [dovepress.com]

  Parallel with his treatment for the mycotic infection, his steroid therapy dose was gradually decreased and his nephrotic syndrome improved. Two months into his treatment, he experienced a recurrent infection on the right leg. [ann-clinmicrob.biomedcentral.com]

• Pallor

  General examination revealed marked pallor. On local examination, a cystic, fluctuant parietal swelling of 6 x 3 cm size was seen in the hypogastric region. There were no local signs of acute inflammation. [jpgmonline.com]

• Aspiration

  Microbiology - In order to define optimal therapy, identification of the causative agent is imperative and procedures such as fine-needle aspiration cytology (FNAC) or deep-seated biopsy are necessary to obtain a valid sample for an investigation. [symptoma.com]

  The distinction between eumycetoma and actinomycetoma in fine needle aspiration cytology (FNAC) is as accurate as in histopathology, as demonstrated in the present case. [ncbi.nlm.nih.gov]

  Fine needle Aspiration Cytology ofMycetoma:• Mycetoma can beaccurately diagnosed byFine Needle Aspiration(FNA) cytology. [slideshare.net]

  In endemic areas, various diagnostic tests and techniques are in use to achieve that, and that includes grain culture, surgical biopsy histopathological examination, fine needle aspiration cytological (FNAC) examination and in certain centres molecular [biorxiv.org]

• Hemoptysis

  Nine months prior to presentation, he developed mild daily hemoptysis. Oral voriconazole was initiated with temporary cessation of hemoptysis. [aspergillus.org.uk]

  However, presentation may also be with hemoptysis, which can be massive and life-threatening. We describe the case of a 50-year-old man with a history of prior pulmonary tuberculosis, with recurrent episodes of cough and hemoptysis. [ncbi.nlm.nih.gov]

  A 44-year-old African American male previously treated for pulmonary tuberculosis 11 years earlier presented with moderate hemoptysis and infiltrates in the right upper lobe on chest radiograph. [journals.lww.com]

  Black-Grain Mycetoma by Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry. ( 28592546 ) 2017 29 Closing the mycetoma knowledge gap. ( 28992217 ) 2017 30 Metastatic Cancer Mimicking a Mycetoma. ( 28207281 ) 2017 31 Persistent Hemoptysis [malacards.org]

  Recurrent bleeding after arterial embolization in patients with hemoptysis. Chest, 97 (1990), pp. 541-546 [12.] R.G. Fraser, J.A.P. Paré. Diagnosis of the chest. 2.a ed., Saunder, (1979), [14.] A.M. Curtis, G.J. Walker Smith, C.E. Ravin. [archbronconeumol.org]

• Cough

  We describe the case of a 50-year-old man with a history of prior pulmonary tuberculosis, with recurrent episodes of cough and hemoptysis. He was diagnosed to have mycetoma in the left upper lobe cavity. [ncbi.nlm.nih.gov]

  A 65-year old man with biopsy-proven FC sarcoidosis presented with hemoptysis of ½ cup daily, weight loss, persistent cough, and dyspnea. He had no chest pain, fever, chills, or night sweats. [aspergillus.org.uk]

  Patients will usually have very minor symptoms, such as a mild cough, and little evidence of systemic inflammation. When symptoms progress, patients may present with weight loss, productive cough, fatigue and shortness of breath. [journal.copdfoundation.org]

  Amongst symptomatic, the most common symptoms include cough and haemoptysis. [priory.com]

  The patient did not give a history of fever, cough, cold, and TB in past. Patient had no other systemic complaints. Patient had taken ayurvedic treatment, but there was no improvement. [jpgmonline.com]

• Dyspnea

  He continued to have gradually worsening dyspnea on exertion with increasing oxygen requirements up to 4 liters per day. [journal.copdfoundation.org]

  A 65-year old man with biopsy-proven FC sarcoidosis presented with hemoptysis of ½ cup daily, weight loss, persistent cough, and dyspnea. He had no chest pain, fever, chills, or night sweats. [aspergillus.org.uk]

  Browse recently published Learning/CME Learning/CME View all learning/CME CME A Trial of a Shorter Regimen for Rifampin-Resistant Tuberculosis Case 10-2019: A 69-Year-Old Man with Progressive Dyspnea Mucinous Ovarian Carcinoma Challenge Yourself Interactive [nejm.org]

  During hospitalization, the patient had laryngeal dyspnea which required tracheostomy. A panendoscopy performed under general anesthesia found diffuse edema of the entire larynx and hypopharynx, with black grains on the mucosa. [medcraveonline.com]

• Hematemesis

  We rehospitalized the patient six months later for hematemesis and epistaxis all in a context of general deterioration ( Figure 4 ). After symptomatic treatment, the exit was done after two weeks, the death occurred one month after discharge. [medcraveonline.com]

• Ulcer

  Abstract A 13-year-old girl presented with multiple painless purulent ulcers with raised borders on the medial aspect of the sole of her right foot associated with inguinal lymphadenopathy for the past 4 years. [ncbi.nlm.nih.gov]

  Ulcerations occurred near the openings of the fistulous tracts. The culture was positive for Nocardia brasiliensis. Case III (Figs. 3 and 4): G D. [pubs.rsna.org]

  Mycetoma presents with a chronic indurated ulcerated plague with swelling and yellowish discharge of sulfur granules. [jocr.co.in]

  Leprosy Syphilis Malignant neoplasm Tropical ulcer[17] Botryomycosis,[9] a skin infection usually caused by the bacteria Staphylococcus aureus. Prevention[edit] No vaccine is available. [en.wikipedia.org]

• Subcutaneous Nodule

  Examination of the plantar, dorsal, and medial surfaces of the foot (Panels A, B, and C, respectively) showed soft-tissue swelling, multiple red, boggy, subcutaneous nodules, and draining sinus tracts. [nejm.org]

  (b) Multiple subcutaneous nodules and sinuses on dorsum of the foot Click here to view On examination, diffuse swelling of right foot with multiple subcutaneous nodules on dorsum and sole of the foot are observed. [jdrntruhs.org]

  Symptoms and Signs of Mycetoma The initial lesion of mycetoma may be a papule, a fixed subcutaneous nodule, a vesicle with an indurated base, or a subcutaneous abscess that ruptures to form a fistula to the skin surface. [msdmanuals.com]

  Mycetoma initially presents as a slowly progressive and painless subcutaneous swelling, which is usually firm and rounded but it can also be soft and lobular. The subcutaneous nodule increases in size and secondary nodules might evolve as well. [microrao.com]

• Skin Ulcer

  Ulcer and Pyoderma 141 21 Cellulitis and Erysipelas 151 Necrotizing Fasciitis 157 23 Human and Animal Bites 161 24 Lice Scabies and Myiasis 167 25 Superficial Fungal Diseases of the Hair Skin and Nails 173 Figure 2510 Method for 179 26 Mycetoma Madura [books.google.es]

• Facial Pain

  Early symptoms include: Fever Nasal congestion Facial pain Late symptoms include: Facial numbness Swelling around the eye Loss of vision Mental status changes Invasive fungal sinusitis can progress within hours to days and lead to intra-orbital and intra-cranial [surgery.wisc.edu]

  Pain. ( 27046035 ) Kauh CY...Lucarelli MJ 2017 35 Madura foot caused by Gordonia terrae misdiagnosed as Nocardia. ( 27270783 ) Zampella JG...Aguh C 2017 36 Dot-in-Circle Sign - A Diagnostic MRI Sign for "Madura Foot". ( 28302229 ) Javed F...Babar S 2017 [malacards.org]

• Epistaxis

  We rehospitalized the patient six months later for hematemesis and epistaxis all in a context of general deterioration ( Figure 4 ). After symptomatic treatment, the exit was done after two weeks, the death occurred one month after discharge. [medcraveonline.com]

• Facial Ulceration

  We report the case of a 13-year-old male patient who received 5-year-old cervico-facial ulcer tumefaction, 6 months after mental trauma, and long-term herbal treatment. [medcraveonline.com]

A properly obtained patient history containing information about the course of symptoms and occupancy may reveal the possible mode of infection and consequently, the underlying pathogen. Moreover, communicating nodular lesions and syrup-like exudate can be observed during a physical examination, which could be sufficient to make a presumptive diagnosis. In fact, the color of grains can indicate the cause of mycetoma in active phases of the disease - white, yellow or red grains are suggestive of bacterial etiology, while fungal grains are usually black or pale [2] [6]. To confirm mycetoma, however, several diagnostic procedures should be used [6]:

• Imaging studies - X-rays, computed tomography (CT), ultrasonography, or magnetic resonance imaging (MRI) of the affected limb are necessary for determining the extent of lesions and the damage caused to the musculoskeletal, vascular and subcutaneous tissues [4] [6].
• Microbiology - In order to define optimal therapy, identification of the causative agent is imperative and procedures such as fine-needle aspiration cytology (FNAC) or deep-seated biopsy are necessary to obtain a valid sample for an investigation [6]. Subsequent microscopic examination (using various stains) or cultivation using gram and Ziehl-Neelsen (ZN) stains are recommended techniques to discern between eumycetoma and bacterial pathogens. Skin tests using antigens of actinomycetes and serology have shown to be ineffective diagnostic tools, but the use of molecular methods - polymerase chain reaction (PCR), to detect bacterial or fungal DNA in the lesions is demonstrating excellent results. Its availability in general practice, however, is yet to occur, especially in endemic countries [2] [6].

• Scedosporium

  We report a case of mycetoma caused by Scedosporium apiospermum in the right foot of a 45-year-old farmer in north India. [ncbi.nlm.nih.gov]

  According to the latest molecular studies S. apiospermum is a species complex, comprising five distinct species: S. apiospermum, Scedosporium aurantiacum, S. boydii, Scedosporium minutisporum, and Scedosporium dehoogii. [ann-clinmicrob.biomedcentral.com]

  Fusarium spp Neotestudina rosatii Aspergillus nidulans Aspergillus flavus Microsporum ferrugineum Microsporum audouinii Microsporum langeronii Scedosporium apiospermum Scedosporium boydii (formerly Pseudallescheria boydii ) Actinomycetoma White to yellow [dermnetnz.org]

The treatment which should be started early is at first a drug treatment. [faoj.org]

Treatment and prognosis The treatment is chosen only after distinguishing if the disease is an actinomycetoma or a eumycetoma. [afwgonline.com]

Voriconazole appears to be a promising drug for the treatment of S. apiospermum mycetomas. [ncbi.nlm.nih.gov]

In such cases, combination of medical treatment before and after surgery results in the most successful outcome. Currently, itraconazole and ketoconazole are still the best treatment options. [microrao.com]

Despite the need for prolonged treatment, prognosis is usually good with proper therapy. The longer the infection has been present prior to treatment, the more likely complications and disability will occur [4]. [dermnetnz.org]

Treatment and prognosis The treatment is chosen only after distinguishing if the disease is an actinomycetoma or a eumycetoma. [afwgonline.com]

Prognosis The prognosis is poor for fungal mycetomas. The documents contained in this web site are presented for information purposes only. [orpha.net]

From being uniformly fatal five decades ago to a current survival rate of 64% to 100%, the prognosis of Candida endocarditis has changed dramatically with the use of antifungal therapy alone or in combination with surgery. [ncbi.nlm.nih.gov]

Prognosis and therapy Mycetomas caused by fungi are usually resistant to chemotherapy [1895], although anecdotal reports of response to long-term therapy with ketoconazole has been appeared [1413, 2403]. [drfungus.org]

Treatment and prognosis Possible deformation and loss of function may eventually be fatal. [radiopaedia.org]

Complete patients' characteristics and etiological agents are reported in Table 1. In 2 cases, the infection was acquired in India, in 2 in Ethiopia, an in 1 case each in Senegal, Tanzania, Honduras, and Italy. [karger.com]

[…] early diagnosis of the disease is necessary to prevent disfigurement, and identification of the etiologic agent is required for guiding management. [afwgonline.com]

Definitions Mycetomas are subdivided by their causative agents eumycetoma or eumycotic mycetoma etiologic agent f ungi most often Madurella mycetomatis ( maduromycosis ) actinomycetoma or actinomycotic mycetoma etiologic agent filamentous bacteria most [radiopaedia.org]

In fact, the color of grains can indicate the cause of mycetoma in active phases of the disease - white, yellow or red grains are suggestive of bacterial etiology, while fungal grains are usually black or pale. [symptoma.com]

There are various etiological agents of eumycetoma, commoner ones are M. mycetomatis, M. grisea, Acremonium spp. and Fusarium spp. [jlponline.org]

Eumycetoma and actinomycetoma–an update on causative agents, epidemiology, pathogenesis, diagnostics and therapy. J Eur Acad Dermatol Venereol 2015;29:1873-1883. van de Sande WW. [afwgonline.com]

Also, we will review the history of the disease through epidemiological and etiological aspects. [scielo.br]

Her research interest focuses on invasive fungal infections to improve diagnostic and treatment strategies through a better understanding of the epidemiology […] [research.pasteur.fr]

Summary Epidemiology Annual incidence is unknown. The condition is endemic in the northern tropical zone and was first described by McGill in the area of Madura (hence the term 'Madura foot') during the last century. [orpha.net]

Hence, paradoxical responses in context other than mycobacterial infection in an immunocompromised host could provide insights into the pathophysiology and the optimal strategy for treatment. [ncbi.nlm.nih.gov]

Author Contacts Gianluca Nazzaro, MD Department of Pathophysiology and Transplantation Università degli Studi di Milano, I.R.C.C.S. [karger.com]

Pathophysiology The body parts affected most commonly in persons with mycetoma include the foot or lower leg, with infection of the dorsal aspect of the forefoot being typical. [avensonline.org]

European College of Veterinary Pathologists Topics and areas of interest Host-pathogen interactions; Pathophysiology of infectious diseases Barrier crossing / Innate immune defenses Pathogen-endothelium interactions Neuropathology Second-opinion diagnosis [research.pasteur.fr]

The pathophysiology of this disease is not well understood. Some fungi that produce mycetoma also produce melanin, which is a virulence factor for many fungi. Toxins are not produced by the organisms causing mycetoma. [infectiousdiseaseadvisor.com]

Prevention & Control Mycetoma is not a notifiable disease (a disease required by law to be reported) and no surveillance systems exist. There no preventable or control programmes for mycetoma yet. [who.int]

Mycetomas can be preventing by wearing proper clothing and strong shoes without open toes. Regular washing and bathing can also prevent risk of mycetomas. For treatment, antifungal and/or antibacterial drugs are required. [know-the-cause.com]

[…] the most suitable approach for minimizing the caseload. [1], [2] The need of the hour is to formulate a holistic public health strategy, comprising of a better surveillance system, investment in research to promote the development of cost-effective preventive [cjhr.org]

Health care providers and researchers believe that wearing shoes might prevent injuries that can lead to mycetoma. [cdc.gov]

1. Welsh O, Al-Abdely HM, Salinas-Carmona MC, et al. Mycetoma Medical Therapy. PLoS Negl Trop Dis. 2014;8(10):e3218
2. Venkatswami S, Sankarasubramanian A, Subramanyam S. The madura foot: looking deep. Int J Low Extrem Wounds. 2012;11(1):31-42.
3. Bonifaz A, Tirado-Sánchez A, Calderón L, et al. Mycetoma: experience of 482 cases in a single center in Mexico. PLoS Negl Trop Dis. 2014;8(8):e3102.
4. Suleiman SH, Wadaella ES, Fahal AH. The Surgical Treatment of Mycetoma. Wanke B, ed. PLoS Negl Trop Dis. 2016;10(6):e0004690.
5. Hemalata M, Prasad S, Venkatesh K, et al. Cytological diagnosis of actinomycosis and eumycetoma: a report of two cases. Diagn Cytopathol. 2010;38(12):918-920.
6. van de Sande WW, Fahal AH, Goodfellow M, et al. Merits and pitfalls of currently used diagnostic tools in mycetoma. PLoS Negl Trop Dis. 2014; 8(7):e2918.