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Mycetoma Foot Central JSM Foot and Ankle Bringing Excellence in Open Access Review Article *Corresponding author Elsheikh Mahgoub, Department of Microbiology, Mycetoma Foot University of Khartoum, Sudan, Email: Submitted: 15 March 2017 Elsheikh Mahgoub* Accepted: 23 March 2017 Department of Microbiology, University of Khartoum, Sudan Published: 25 March 2017 ISSN: 2475-9112 Abstract Copyright Mycetoma is a chronic progressive granulomatous infection characterized © 2017 Mahgoub by a painless swelling, development of sinuses that discharge pus and grains of different colors. It will ultimately involve bone that shows cavities in a plain x-ray. It OPEN ACCESS is important to determine whether the cause is bacterial (Actinomycetoma) or fungal (Eumycetoma) because the former is treated by antibiotics and the latter by antifungal Keywords drugs. Laboratory diagnosis is established by culture of grains or stained sections • Actinomycetoma for Histopathological examination. A good approach for treatment is removal of the • Eumycetoma affected tissue followed by antibiotic or antifungal for a period of about nine months. • Madurella mycetomatis The patient is to be followed up carefully for fear of side effects of the drug. INTRODUCTION Mycetoma Foot is an improvement on the old name Madura On examination the skin is attached to a firm swelling with in Actinomycetoma. Skin may remain normal or become dark foot which was coined by Carter in 1874 to describe a condition defined border in case of Eumycetoma but the margin diffuses colored or depigmented. It may also show more sweating than that affected a patient from Madura District in South West India the other limb. The inguinal lymph nodes may be enlarged due [1]. Hence derivation of the genera Madurella, Actinomadura and the species madurae. The disease is no longer limited to India therefore warned not to forget examining the regional lymph but has been reported globally with high endemicity in Mexico, to inflammation or spread of the organism to them. Doctors are nodes [3]. Venezuela, Sudan, Saudi Arabia and immigrants to Europe and America. RADIOLOGY Countries of the Mycetoma belt extend between the Equator On a plain x-ray Mycetoma lesions show a dense granuloma and the tropics of Cancer and Capricorn. These areas have hot of tissue and bone cavities which are small and numerous in weather and enjoy rain only for three months and nine months of Actinomycetoma (Figure 2), but large and few in Eumycetoma. dry season. Such weather results in growth of savannah type of On ultrasound grains show oncogenic shadows; extent of lesion vegetation and Acacia trees armed with thorns. Persons affected are those who work bare footed like farmers and animal herders isCAUSATIVE well exemplified ORGANISMS by MRI [4-6]. but no occupation is immune in endemic areas. Men are affected more than women. Though patients who report to hospital are More than 59 organisms have been recorded causing aged between 20 and 40 years. Children are also seen [2]. mycetoma [7]. However common fungi are Madurella mycetomatis, M.grisea, Leptosphaeria senegalensis, Petrilidium CLINICAL PICTURE The disease affects the foot in 70% of cases but Mycetoma from other body sites has also been reported [2]. Mycetoma is initiated by entry of the organism from soil through thorn prick, wood splinter or stone cut or any cause of breach of the skin. Next subcutaneous tissue is affected and ultimately bone. After an incubation period not less than three months a swelling the size of a pea appears; and if not removed will gradually progress to a large size. Patients usually report late to hospital because they think that it will get cured by itself. If untreated swelling increases, sinuses develop and serosanginous discharge containing fungal or bacterial grains and pus pour out (Figure 1). Figure 1 Actinomycetoma Foot. Cite this article: Mahgoub E (2017) Mycetoma Foot. JSM Foot Ankle 2(2): 1023. Mahgoub (2017) Email: Central Bringing Excellence in Open Access boydii while common bacteria are Actinomadura madurae, A.pelletierii, Nocardia brasiliensis and Streptomyces somaliensis. Organisms may vary from country to country or from one area to the other within the same country. DIAGNOSIS A well-developed mycetoma foot is easily diagnosed by the triad of progressive painless swelling, sinuses and discharged . For laboratory grains. Radiograph shows bone cavities containing grains are needed [2,8]. Fungi are grown on 2% glucose confirmation a deep seated biopsy or fine needle aspirate nutrient agar containing a wide spectrum antibiotic (Sabourauds Figure 4 Actinomadura madurae culture. and then transferred to serum agar or brain heart infusion agar. agar). Bacteria are cultured on Lowenstein Jensen medium first Fungi grow as molds and M. mycetomatis, the commonest fungus, produces a brown diffusible pigment (Figure 3). Bacterial colonies are smooth bearing the color of grains which is either white, yellow, orange or red depending on the species (Figure 4). Histopathological sections are stained with Haematoxylin and eosin. Each individual grain has its own affinity for the stain; configuration and size which is characteristic Serological diagnosis is performed in few centers for diagnosis (Figures 5 & 6). Grains are situated in the middle of neutrophils. Figure 5 M. myctomatis grain H/E x400, note brown pigment. Figure 2 Small multiple cavities Actinomycetoma due to S. somaliensis at the base of the big metatarsal bone. Figure 6 Large Actinomadura madurae grain, note dark Haematoxylin stain in the periphery. Figure 3 M. mycetomatis culture, note secretion of the brown pigment in the Figure 7 CIE showing deep-blue precipitation lines between serum and medium. antigen. JSM Foot Ankle 2(2): 1023 (2017) 2/4 Mahgoub (2017) Email: Central Bringing Excellence in Open Access and follows up of treatment. These include counter-immuno Failure of treatment often is due to misdiagnosis of the causative electrophoresis “CIE” (Figure 7), ELISA and Immunoblotting [9- organism or noncompliance of the patient in taking the drug M. mycetomatis from soil [12] (Figure 8 & 9). (Figure 7). 11]. PCR has been used to detect WHO GETS A MYCETOMA? TREATMENT Not everybody who walks bare footed and exposed to injury A wise approach to treatment is to seek early small lesions even if he or she lives in an endemic area gets a mycetoma. These which can be completely excised. In advanced lesions surgery is [18,19]. Such patients may get two mycetomas of the same or patients were found deficient in their cell mediated immunity as much as possible of the affected soft tissue. Antibiotics or different organisms. There seems to be a genetic predisposition performed in bloodless field using a tourniquet and removing antifungal are prescribed depending on the type of mycetoma because close relatives living in the same area get mycetoma. to prevent recurrence. For Actinomycetoma several regimens REFERENCES of combination therapy has been reported but amicasin in 1. Mahgoub ES. M st Edn. William Heinemann Medical Books. 1973. urray IG. Mycetoma 1 2. nd Edn. 2014. 3. MahgoubEl Hassan ES, AM, Murray Mahgoub IG. Mycetoma ES. Lymph 2 node involvement in mycetoma. 4. TransAbd El-Bagi R Soc TropME, FahalMed Hyg. AH. 1972;Mycetoma 66: 165-169. revisited incidence of various 5. radiologicalFahal AH, El signs. Sheikh Saudi HA, Med Homeida J. 2009; MA,30: 529-533.El Arabi YE, Mahgoub ES. 1122. Ultrasonic imaging in mycetoma. British J of Surgery. 1997; 84: 1120- 6. Arbab MA, Idris MN, Sokrab TE, Aeedes, Ali GM, Tarig MY, et al. Clinical presentation and CAT scan findings in mycetoma of the head. East 7. African Medical J. 1998; 75: 246-248. Eumycotic Mycetoma, in Manual of Clinical Microbiology. 2007; 1918- De Hoog GS, AhmedAO, McGinnis MR, Padhye MR. Fungi causing Figure 8 Eumycetoma due to M. mycetomatis before surgery and medical 1827. treatment. 8. Elhag IA, Fahal AH, Khalil EAG. Fine needle aspiration cytology of 9. mycetoma. Acta Cytologica. 1997; 49: 461-464. the diagnosis of mycetoma and its sensitivity as compared to Gumaa SA, Mahgoub ES. Counter immunoelectrophoresis in 10. immunodiffusion.Salinas Carmona Sabouraudia.MC, Welsh 1975; O, Casillas13: 309-315. SM. Enzyme linked immunosorbent assay for serological diagnosis of Nocardia brasiliensis and clinical correlation with Mycetoma infection. J Clinical 11. Microbiology.Elbadawi HS, 1993; Mahgoub 31: 2901-2906. ES, Mahmoud MN, Fahal AH. Use of Immunoblotting in testing Madurella mycetomatis specific antigen. 12. TransAhmed R AO, Soc Mukhtartrop Med MM, Hyg. Kools-Sijmons 2016; 110: 312-316. M, Fahal AH, de Hoog S, van den Ende BG, et al. Development of a species-specific PCR-restriction fragment length polymorphism analysis procedure for identification Figure 9 The same patient after treatment. 3178. of Madurella mycetomatis. J Clinical Microbiology. 1999; 37: 3175- 13. Mahgoub ES. Medical management of mycetoma. Bull World Health cycles coupled with cotrimoxasole is the best (beware renal and ototoxicity by close follow up) [13-15]. In Eumycetoma 14. Organ. 1976; 54: 303-310. itraconazole or voriconazole are prescribed [17]. Hay RJ, Mahgoub ES, Leon G, Alsogair S. Current concepts in treatment ketoconazole was reported before [16] but due to its side effects 15. of Mycetoma. Med Vet Mycology. 1992; 30: 41-49. Medical treatment of Mycetoma may take 9-12 months. Actinomycetoma due to Nocardia spp. with amoxicillin-clavulaniate. Bonifaz A, Flores P, Saul A, Carrasco-Gerard E, Ponce RM. Treatment of Brtit J Dermatology. 2007; 56: 308-311. JSM Foot Ankle 2(2): 1023 (2017) 3/4 Mahgoub (2017) Email: Central Bringing Excellence in Open Access 18. 16. Mahgoub ES, Gumaa SA. Ketoconazole in the treatment of eumycetoma Mahgoub ES, Gumaa SA, El Hassan AM. Immunological status of due to Madurella mycetomii. Trans R Soc Trop Med Hyg. 1984; 78: 19. mycetomaMahgoub ES. patients. Experimental Bull Soc infectionPathol Exot of Filiales.athymic 1977; nude 70: New 48-54. Zealand 17. 376-379. Zijlstra EE, J Van de Sande W, Welsch O, Mahgoub ES, Goodfellow mice, nu nu strain with mycetoma agents.
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