Edit concept Question Editor Create issue ticket

Mycetoma

Mycetomas

Mycetoma is a term for a subcutaneous infection caused by either by bacterial (actinomycetes, most important representative being Nocardia sp.) or fungal (eumycetoma) pathogens. The condition is chronic and may be severely debilitating, with main clinical features being development of painless communicating nodules on distal lower extremities.


Presentation

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]
  • Two patients presented with recurrent soft tissue masses, which were operated on several times and not suspected to be of infective aetiology. The third patient had typical clinical features with a history of blackish granule discharge.[ncbi.nlm.nih.gov]
  • A 58-year-old agricultural worker from a remote Western province farming community in Saudi Arabia presented with a 2-year history of right plantar foot soft tissue mass.[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]
  • We present a case of an asymptomatic infant with multiple Candida tricuspid valve mycetomas. Complete cure was achieved by combined tricuspid valve repair and fluconazole therapy.[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]
  • 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]
  • 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]
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]
  • Histopathological examination of the biopsy tissue was suggestive of actinomycotic mycetoma. Streptomyces spp. was isolated from blood culture. The patient was successfully treated with trimethoprim-sulfamethoxazole and crystalline penicillin.[ncbi.nlm.nih.gov]
  • Given antibiotic resistance concerns, we suggest that antimicrobial susceptibility testing should be done for the majority of Nocardia species without well-established resistance patterns.[ncbi.nlm.nih.gov]
  • This sign is an easily recognisable and unique appearance that is highly suggestive of mycetoma.[ncbi.nlm.nih.gov]
  • We describe a patient with mycetoma or Madura foot, in which histopathological stains of the bone and surface cultures suggested three different organisms including Nocardia species as the cause.[ncbi.nlm.nih.gov]
Neglect
  • The disease was only recently added to the World Health Organization (WHO) list of neglected tropical diseases in 2013, under ‘other neglected conditions’.[mycetoma.edu.sd]
  • Mycetoma is so neglected it isn’t even on the WHO’s list of 17 Neglected Tropical Diseases. Mycetoma commonly affects the very poor and especially folks who work in agriculture, labor, and herding .[globalcontagions.com]
  • In May 2013 the World Health Assembly adopted a resolution urging all member states to commit to specific measures regarding all neglected tropical diseases on the WHO list.[gaffi.org]
  • "We are finally starting to roll the ball towards ending the neglect of patients suffering from mycetoma."[news-medical.net]
  • Starting from scratch-the unique neglect of mycetoma. Lancet Infect Dis 2016;16:1011-2. [ PUBMED ] 3. Zijlstra EE, van de Sande WW, Fahal AH. Mycetoma: A long journey from neglect. PLoS Negl Trop Dis 2016;10:e0004244.[cjhr.org]
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]

Workup

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]
  • On the other hand, histopathology and fungal culture confirmed it to be a case of chromoblastomycosis caused by Fonsecaea pedrosoi.[ncbi.nlm.nih.gov]
  • The causative agents of actinomycetoma included Nocardia brasiliensis, N. asteroides, N. otitidiscaviarum, N. ninae and Gordonia terrae, and the causative fungi of eumycetoma were identified as Madurella mycetomatis, Fonsecaea pedrosoi and Acremonium[ncbi.nlm.nih.gov]

Treatment

  • Clinical studies of treatments including an NSAID should be conducted to confirm this finding.[ncbi.nlm.nih.gov]
  • Voriconazole appears to be a promising drug for the treatment of S. apiospermum mycetomas.[ncbi.nlm.nih.gov]
  • Paradoxical responses, defined as initial clinical worsening despite appropriate treatment, are common in tuberculosis but rare in deep mycoses in non-immunocompromised hosts.[ncbi.nlm.nih.gov]
  • Most of the patients claimed no benefits from the herbal treatment. Ninety one patients (29.3%) had encountered complications with herbal treatment.[ncbi.nlm.nih.gov]
  • Long treatment duration was a significant predictor of reduced odds of dropout (OR 0.5; 95% CI 0.3-0.8). There is a great demand for effective and efficient mycetoma treatment.[ncbi.nlm.nih.gov]

Prognosis

  • 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]
  • Identification of the causative organism and the disease extension are the first steps in the management of the affected patients and predicting disease treatment outcome and prognosis.[ncbi.nlm.nih.gov]
  • Strong clinical suspicion, exact categorization of lesion into eumycotic or actinomycotic along with culture correlation, is essential for prognosis and effective therapy.[ncbi.nlm.nih.gov]
  • Prognosis The prognosis is poor for fungal mycetomas. The documents contained in this web site are presented for information purposes only.[orpha.net]
  • Further studies are needed to determine to what extent the grading system can be used to determine a patient's prognosis. Copyright 2012 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.[ncbi.nlm.nih.gov]

Etiology

  • Mycetoma is defined as a fungus ball that fills a preexisting lung cavity, most frequently being of tuberculous or sarcoid etiology.[ncbi.nlm.nih.gov]
  • Besides Nocardia otitidiscaviarum, Pseudozyma aphidis was isolated from deep tissue culture, and the identification of the etiologic species was ascertained by DNA sequencing.[ncbi.nlm.nih.gov]
  • Also, we will review the history of the disease through epidemiological and etiological aspects.[ncbi.nlm.nih.gov]
  • Abstract Medical treatment of mycetoma depends on its fungal or bacterial etiology. Clinically, these entities share similar features that can confuse diagnosis, causing a lack of therapeutic response due to inappropriate treatment.[ncbi.nlm.nih.gov]
  • The etiologic agents range from bacteria to fungi existing free in nature as soil or plant saprophytes gaining entrance into the tissues through abrasion or implantation. Actinomycetoma is caused by aerobic species of actinomycetes.[aspergillus.org.uk]

Epidemiology

  • Based on the KAP and epidemiological data, several health education sessions were conducted in the village for different target groups.[ncbi.nlm.nih.gov]
  • 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]
  • In this retrospective study we report epidemiologic, clinical and microbiologic data of mycetoma observed in the General Hospital of Mexico in a 33 year-period (1980 to 2013).[ncbi.nlm.nih.gov]
  • Also, given its relative importance locally, improvements in clinical and laboratory diagnostics and knowledge of the epidemiology of the disease are badly needed.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • 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]
  • 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

  • By prompt and reliable diagnosis with corresponding antimicrobial administration, we can prevent further progression and limb disability.[ncbi.nlm.nih.gov]
  • Prevention & Control Mycetoma is not a notifiable disease (a disease required by law to be reported) and no surveillance systems exist. There are no prevention 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]
  • 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]

References

Article

  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.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 22:44