Lymph node involvement in mycetoma

Epidemiological observations and management challenges in extrapedal mycetoma: A three-decade review of 420 cases

Mycetoma is a serious, destructive, disfiguring chronic granulomatous inflammatory disease affecting the subcutaneous tissues that spread to involve the skin, deep tissues and bone. The disease predominately affects the limbs, and extrapedal mycetoma is rarely reported. The reported extrapedal ones are characterised by high morbidity and mortality. This communication reports on 420 patients with extrapedal mycetoma seen and managed at the Mycetoma Research Centre (MRC), University of Khartoum, between January 1991 and December 2021. In this descriptive, cross-sectional, hospital-based study, the electronic records of all mycetoma-confirmed patients seen during the study period were carefully and meticulously reviewed. The confirmed patients with extrapedal mycetoma were included in this study. The study included 420 patients with extrapedal mycetoma, 298 (70.7%) had eumycetoma, and 122 (29.3%) had actinomycetoma. There were 343 male patients (81.7%) and 77 (18.3%) females, with a male-to-female ratio of 4:1. Their ages ranged between 1.5 and 95 years, with a median of 28 years. Most of the patients were students and farmers. The majority of patients were from El Gezira, North Kordofan, and the White Nile States. Mycetoma was painful in 21%, and a family history of mycetoma was recorded in 11.5% of patients. The buttocks (37.9%) and head and neck (16.9%) were affected most. Less frequently affected sites were the trunk and back (12%) each, abdominal and chest walls (4.5%) each and loin (1%). The prominent clinical presentation findings were multiple sinuses discharging grains (55%), massive swellings (46%), and lymphadenopathy (11.5%). Less commonly observed clinical findings were local hyperhidrosis (5.3%) and dilated tortuous veins close to mycetoma lesions (0.5%). The study showed that 204 patients (48.6%) had clinical improvement in terms of decreased lesion size and healing of sinuses following medical therapy. Sixty-six patients (15.7%) had no noticeable improvement. The lesion continued progressing despite treatment in 44 patients (10.5%). In the study, 118 patients were on regular follow-up, and in this group, a cure was documented in 25 patients (21.1%) with eumycetoma and 23 (19.4%) with actinomycetoma. Post-operative recurrence among eumycetoma patients was 40%, with a 1% mortality rate. The treatment outcome was unsatisfactory, characterised by a low cure rate, high recurrence (40%) and follow-up dropout (57%) rates. This emphasises the importance of early case detection and management, objective health education programmes and thorough patient counselling to urge people to seek treatment early and reduce dropouts.

A study of 87 mycetoma patients seen at three health facilities in Nouakchott, Mauritania

BACKGROUND

Mycetoma is a chronic, progressive and destructive inflammatory disease that affects the skin, subcutaneous and other tissues. The objective of this study was to identify all cases of mycetoma diagnosed in three health facilities in Nouakchott, Mauritania during 2016-2018.

METHODS

This retrospective hospital-based study was conducted at the Dermatology, Orthopedics, Mycology and Pathology departments of the National Hospital Center of Nouakchott, the Military Hospital of Nouakchott and the National Institute for Research in Public Health of Nouakchott.

RESULTS

Eighty-seven patients were included in this study. They comprised 65 male patients (74.71%) and 22 females (25.28%) with a gender ratio of 4:1. The mean age was 41.87 y and ages ranged from 14 to 70 y. The most common age group was 40-45 y (11%). The foot was the most frequently affected site seen in 60 patients (69%), followed by ankle and hand with 6 patients each (7%). In the study, 56 patients (64%) had regional lymphadenopathy. Forty-nine patients (56%) had bone involvement. Thirty-two patients (37%) had medical treatment. Twenty-seven patients (87%) received fluconazole and four patients (13%) had co-trimoxazole treatment.

CONCLUSION

The mycetoma patients seen in these three centres were mainly male farmers from rural areas. The lesions were seen mainly in the lower limbs and the majority had bone involvement radiologically.

Massive complicated secondary inguinal mycetoma: a case series

Mycetoma is a chronic subcutaneous granulomatous disease of the soft tissue and extremities. Herein we report four cases of mycetoma caused by different agents, two caused by Madurella mycetomatis, with Actinomadura madurae and Streptomyces somaliensis affecting the others. These lesions originated at different sites but eventually spread to the inguinal region. The exact mechanism for such spread is still unknown and the clinical presentation of our case series was distinctive and required intensive follow-up for appropriate management.

Mycetoma in Sudan: experience of the Mycetoma Project from 1968 to 1991

International collaboration on research on neglected tropical diseases (NTDs) is regarded as a norm, but it was not always so. This article is an account of a growing international collaboration on the diagnosis and treatment of mycetoma that started in Sudan in the 1960s and has grown and flourished up to the present day.

Pulmonary Madurella mycetomatis mycetoma secondary to knee eumycetoma, Senegal

Mycetoma is a neglected tropical disease which is endemic in Senegal. Although this subcutaneous mycosis is most commonly found on the foot, extrapodal localisations have also been found, including on the leg, knee, thigh, hand, and arm. To our knowledge, no case of blood-spread eumycetoma has been reported in Senegal. Here, we report a case of pulmonary mycetoma secondary to a Madurella mycetomatis knee eumycetoma. The patient was a 41-year-old farmer living in Louga, Senegal, where the Sudano-Sahelian climate is characterised by a short and unstable rainy season and a steppe vegetation. He suffered a trauma to the right more than 20 years previously and had received treatment for more than 10 years with traditional medicine. He consulted at Le Dantec University Hospital in Dakar for treatment of a right knee mycetoma which had been diagnosed more than 10 years ago. He had experienced a chronic cough for more than a year; tuberculosis documentation was negative. Grains collected from the knee and the sputum isolated M. mycetomatis, confirmed by the rRNA gene ITS regions nucleotide sequence analysis. An amputation above the knee was performed, and antibacterial and antifungal therapy was started with amoxicillin-clavulanic acid and terbinafine. The patient died within a month of his discharge from hospital.

Mycetoma epidemiology, diagnosis management, and outcome in three hospital centres in Senegal from 2008 to 2018

Mycetoma is a neglected tropical disease caused by various actinomycetes or fungi. The disease is characterized by the formation of tumor like-swellings and grains. Senegal is an endemic country where mycetoma cases are under-or misdiagnosed due to the lack of capacities and knowledge among health workers and the community; and where the management of eumycetoma, burdened by a high amputation rate, is currently inadequate. This study aimed to update data on the epidemiology of mycetoma cases diagnosed in three hospital centres in Senegal over a 10 years-period. A total of 193 patients, diagnosed from 2008 to 2018, were included in the study. The most frequent presentation was eumycetoma (47.2%); followed by actinomycetoma (36.8%); it remained undetermined in 16.1% of the patients. The mean age was 38.3 years (68.4% of the patients were between 15 and 45 years-old); the male: female ratio was a 2.94; and most were farmers. One hundred fifty-six (80.8%) patients had used phytotherapy before attending the hospital. Mycetoma was mainly located to the lower limbs (91.2%). Grains were observed in 85% of the patients; including white (25.6%) and yellow (4.3%) grains. The etiological diagnosis was complex, resulting in negative direct microscopy, culture and/or histopathology findings, which explains that 16.1% remained uncharacterized. In most of cases, actinomycetoma were treated with a combination of cotrimoxazole, amoxicillin/clavulanic acid, and streptomycin; whereas eumycetoma cases were treated with terbinafine. The surgery was done in 100 (51.8%) of the patients including 9 in actinomycetoma, 78 in eumycetoma and 13 in undetermined form. The high number of uncharacterized mycetoma in this study, the delay in attending a qualified health-care facility, and the lack of available adequate antifungal drug, point out the need to strengthen mycetoma management capacities in Senegal.

Mycetoma: The Spectrum of Clinical Presentation

Mycetoma is a chronic infection, newly designated by the World Health Organization (WHO) as a neglected tropical disease, which is endemic in tropical and subtropical regions. It follows implantation of infectious organisms, either fungi (eumycetomas) or filamentous bacteria (actinomycetomas) into subcutaneous tissue, from where infection spreads to involve skin, bone and subcutaneous sites, leading to both health related and socioeconomic problems. In common with other NTDs, mycetoma is most often seen in rural areas amongst the poorest of people who have less access to health care. The organisms form small microcolonies that are discharged onto the skin surface via sinus tracts, or that can burrow into other adjacent tissues including bone. This paper describes the clinical features of mycetoma, as early recognition is a key to early diagnosis and the institution of appropriate treatment including surgery. Because these lesions are mostly painless and the majority of infected individuals present late and with advanced disease, simplifying early recognition is an important public health goal.

Mycetoma: reviewing a neglected disease

Mycetoma caused by either filamentous fungi (eumycotic) or bacteria (actinomycotic) has recently been recognized by the World Health Organization as a neglected tropical disease. Although mycetoma is preventable and treatable, especially in the early stages, it carries high morbidity and a huge socioeconomic burden. Skin and subcutaneous tissue is affected, with a classic presentation of hard woody swellings, discharging sinuses and presence of grains (containing the causative organism). Variants with swelling without sinuses have also been described. Left untreated it may involve underlying bone and muscle, leading to permanent disability. Common actinomycotic species include Streptomyces somaliensis, Actinomadura madurae, Actinomadura pelletieri, Nocardia brasiliensis and Nocardia asteroides, while Madurella mycetomatis, Madurella grisea, Pseudoallescheria boydii and Leptosphaeria senegalensis are common eumycotic agents. Men are more commonly affected than women, and the leg is the most frequently affected site. Diagnosis in suspected lesions is made with the help of grain examination, microscopy, imaging (radiography, ultrasonography, magnetic resonance imaging) and culture, and more recently by molecular methods such as PCR and molecular sequencing. Molecular sequencing for both fungi and bacteria is important for rapid and correct diagnosis, especially in culture-negative cases. Treatment is long, more successful in actinomycetoma than eumycetoma, and may require a holistic approach comprising antimicrobials, surgery and rehabilitation. Mycetoma can be prevented by simple measures such as wearing protective garments and shoes, especially in rural areas and during outdoor activities.

Mycetoma: An Update

Mycetoma is a localized chronic, suppurative, and deforming granulomatous infection seen in tropical and subtropical areas. It is a disorder of subcutaneous tissue, skin and bones, mainly of feet, characterized by a triad of localized swelling, underlying sinus tracts, and production of grains or granules. Etiological classification divides it into eumycetoma caused by fungus, and actinomycetoma caused by bacteria. Since the treatment of these two etiologies is entirely different, a definite diagnosis after histopathological and microbiological examination is mandatory, though difficult. Serological test exists but is not so reliable; however, molecular techniques to identify relevant antigens have shown promise. The disease is notoriously difficult to treat. Eumycetoma may be unresponsive to standard antifungal therapy. Actinomycetoma responds to antibiotic therapy, but prolonged treatment is necessary. This review focuses on the etiopathogenesis, clinical features, laboratory diagnosis, and treatment of mycetoma.

Mycetoma: a unique neglected tropical disease

Mycetoma can be caused by bacteria (actinomycetoma) or fungi (eumycetoma) and typically affects poor communities in remote areas. It is an infection of subcutaneous tissues resulting in mass and sinus formation and a discharge that contains grains. The lesion is usually on the foot but all parts of the body can be affected. The causative microorganisms probably enter the body by a thorn prick or other lesions of the skin. Mycetoma has a worldwide distribution but is restricted to specific climate zones. Microbiological diagnosis and characterisation of the exact organism causing mycetoma is difficult; no reliable serological test exists but molecular techniques to identify relevant antigens have shown promise. Actinomycetoma is treated with courses of antibiotics, which usually include co-trimoxazole and amikacin. Eumycetoma has no acceptable treatment at present; antifungals such as ketoconazole and itraconazole have been used but are unable to eradicate the fungus, need to be given for long periods, and are expensive. Amputations and recurrences in patients with eumycetoma are common.

The orthopaedic aspects of mycetoma

This article presents an overview of mycetoma and offers guidelines for orthopaedic surgeons who may be involved in the care of patients with this condition.

Mycetoma: a thorn in the flesh

Mycetoma is a chronic, granulomatous, subcutaneous, inflammatory disease caused by true fungi (eumycetoma) or filamentous bacteria (actinomycetoma). It occurs in the mycetoma belt stretching between the latitudes of 15 degrees South and 30 degrees North and is endemic in relatively arid areas. The organisms are present in the soil and may enter the subcutaneous tissue by traumatic inoculation. Mycetoma commonly affects adults aged 20 to 40 years, predominantly males. The foot is most commonly affected. Both forms of mycetoma present as a progressive, subcutaneous swelling, although actinomycetoma has a more rapid course. Multiple nodules develop which may suppurate and drain through sinuses, discharging grains during the active phase of the disease. Diagnosis may involve radiology, ultrasonic imaging, cytology, culture, histology or immunodiagnosis. Actinomycetoma is amenable to treatment by antibiotics, preferably by combined drug therapy for long periods. Eumycetoma is usually treated by aggressive surgical excision combined with medical treatment.

Internal fistula formation: an unusual complication of mycetoma

This paper reports 2 hitherto undescribed complications of mycetoma, urinary extravasation and expectoration of mycetoma grains due to cutaneo-urethral and cutaneo-pleuro-bronchial fistulae, respectively. The first patient had an infection with Actinomadura madurae which started in the foot and had spread progressively to involve the whole limb, anterior abdominal wall, perineum and urethra. The second patient had Madurella mycetomatis infection of the hand and, in spite of extensive treatment, the infection had spread to the axilla, chest wall, lung and bronchial tree. Both patients died of the sequelae of these complications. The pathogenesis of these unusual complications is discussed.

Phialophora verrucosa: a new cause of mycetoma

A 29-year-old Thai woman had draining sinus tracts, tumefaction, and granules on the plantar aspect of the foot. Phialophora verrucosa was isolated from the lesion. P. verrucosa is a major agent of chromoblastomycosis, which is known to rarely cause subcutaneous phaeohyphomycosis. This dematiaceous fungus has not been previously reported to cause mycetoma. This case illustrates the clinical spectrum of disease of this fungus. The salient features of mycetoma and management options are presented.

Mycetoma

Mycetoma is a chronic infective condition of tropical and subtropical regions. It is commoner in males, especially those in their third or fourth decade who work on the land. The clinical triad of subcutaneous nodule, sinuses and discharge usually leads to diagnosis; the disease is commonly painless. Treatment is by extensive surgical excision of affected areas and may include limb amputation. Recurrence is common, rates ranging from 20 to 90 per cent. Medical treatment may be used on its own or as an adjunct to surgery. Although such therapy may cure over half of those with actinomycetoma (caused by bacteria, mainly aerobic actinomycetes), those affected by eumycetoma (caused by fungi) have a poorer prognosis and may require many years of drug therapy.

Cranial and epidural mycetoma caused by streptomyces somaliensis

The authors report a rare case of cranial and intracranial mycetoma which presented with occipital sinuses, extensive involvement of skull vault and base, an extradural granuloma and intracranial hypertension. Radiological appearances are reviewed. The computerized tomography findings are the first of their kind for this condition. The diagnosis and treatment of this disease are discussed.

Mycoses of the Sudan

Mycoses in the Sudan are still significant and, as well as mycetoma, there are a number of fungal diseases: paranasal aspergillus granuloma, which came into eminence in 1966; actinomycosis; subcutaneous phycomycosis; systemic phycomycosis; post-operative opportunistic infection of the eye with Trichosporon cutaneum and rhinosporidiosis. Mycetoma and paranasal aspergillus granuloma are discussed in detail.