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].

• Soft Tissue Mass

  It has characteristic histologic and genetic features that help distinguish it from other soft tissue masses. We present a case of a soft tissue mass diagnosed in the United States. [ncbi.nlm.nih.gov]

  The mycetoma itself is characterized by a mobile soft tissue mass within a thick-walled cyst or cavity [1–3] (Figure 25.1). There is usually thickening of the pleura adjacent to the cavity. [mayoclinic.pure.elsevier.com]

• Asymptomatic

  We present a case of a 31-year-old male, a known patient with lepromatous leprosy with a type 2 lepra reaction, who presented with a slowly growing asymptomatic swelling with multiple discharging sinuses over the forehead that developed over 6 months. [ncbi.nlm.nih.gov]

  […] parenchymal infection is reported to affect 5 to 8% of solid-organ transplant recipients with a 50 –100% mortality.[5] In HIV seropositve patients, P carinii pneumonia is a major risk factor for pulmonary aspergilloma.[6] The patients with mycetoma are often asymptomatic [priory.com]

  The lesion was asymptomatic, but in the last 30 days, nodules developed over that site were painful and itchy. Those nodules gradually increased in size and then foul smelling discharge started from multiple sinuses. [jpgmonline.com]

  After 7 months, the patient remained asymptomatic. [ann-clinmicrob.biomedcentral.com]

• Localized Pain

  Local pain was reported in 27% of the patients, and only 12% had a family history of mycetoma. The study showed that 57% of the patients had previous surgical excisions and recurrence, and only 4% received previous medical treatment for mycetoma. [ncbi.nlm.nih.gov]

  Local pain is mild or absent, and it worsens only in later stages with more subcutaneous tissue damage or with secondary bacterial infection. Mycetoma has little effect on the general condition of the affected patient and fever is rare [2]. [dermnetnz.org]

• Inguinal 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]

• Aspiration

  The fine needle aspiration (FNA) performed on the swelling yielded purulent material; on microscopy, actinomycosis was diagnosed. On culturing, the pus grew S. griseus. [ncbi.nlm.nih.gov]

  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]

  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]

• Chest Wall Pain

  An 89-year-old man was admitted to the hospital due to intermittent anterior chest wall pain for 1 month. [ncbi.nlm.nih.gov]

• Regurgitation

  We report the case of a 46-year-old male hospitalized for abdominal pain and fever with history of a David procedure followed by an aortic valve replacement due to severe aortic regurgitation. [ncbi.nlm.nih.gov]

• Abdominal Pain

  We report the case of a 46-year-old male hospitalized for abdominal pain and fever with history of a David procedure followed by an aortic valve replacement due to severe aortic regurgitation. [ncbi.nlm.nih.gov]

• Diplopia

  A 31-year-old non-immunocompromised male patient presented with complaints of left hemifacial pain for 1 year and diplopia on looking toward left side for a period of 2 weeks. On examination, he had ipsilateral sixth nerve paresis. [ncbi.nlm.nih.gov]

• Skin Ulcer

  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 and Rash 123 18 Staphylococcal and Streptococcal Toxic Shock 129 19 Classic Viral Exanthems 135 20 Skin [books.google.es]

• Suggestibility

  ENMs were calibrated in known endemic districts and transferred countrywide; model results suggested that risk is greatest in an east-west belt across central Sudan. [ncbi.nlm.nih.gov]

• Confusion

  Clinically, these entities share similar features that can confuse diagnosis, causing a lack of therapeutic response due to inappropriate treatment. [ncbi.nlm.nih.gov]

  It shows poor morphological differentiation and causes confusion among clinicians and microbiologists. [8] 1. McGinnis MR. Mycetoma. Dermatol Clin 1996;14:97-104. [ PUBMED ] 2. Singh H. Perianal Mycetoma. Indian J Surg 1976;38:530-4. 3. Fahal AH. [atmph.org]

  However, in the absence of these features and history, the diagnosis can be confusing. X-rays can provide information regarding osseous involvement. MRI can provide information about soft-tissue involvement. [jocr.co.in]

  Although the clinical picture is characteristic, diagnostic confusion may occur with chronic bacterial osteomyelitis, especially when bone destruction has occurred. Botryomycosis can give a similar picture. [faoj.org]

  Identification of Madurella species has been hampered by the absence of sporulation leading to confusion during the identification process. [journals.plos.org]

• Paresis

  On examination, he had ipsilateral sixth nerve paresis. Investigations revealed a large paranasal sinus lesion that extended in the cavernous sinus. The lesion was partially resected. [ncbi.nlm.nih.gov]

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].

• Fonsecaea Pedrosoi

  Direct KOH mount of the verrucose tissue showed Fonsecaea pedrosoi sclerotic muriform bodies and a biopsy of one granule discharging nodule demonstrated fungal mycetoma. He was put on tab. [ncbi.nlm.nih.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.