Mycetoma

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  • Chronic progressive granulomatous implantation infection of the skin and subcutaneous tissue, usually affecting a single extremity
  • Caused by either fungi or fungal-like bacteria

Background

Microbiology

Epidemiology

  • Present worldwide between 15ºS and 30ºN
  • Within Latin America, Mexico has the highest incidence
  • Also relatively high incidence in Chad, Ethiopia, India, Mauritania, Senegal, Somalia, Sudan, Yemen, and Venezuela
  • More common in poorer, rural communities

Clinical Manifestations

  • Chronic implantation fungal infection characterized by swelling and draining sinuses
  • Can involve deeper tissues such as muscle or bone (in contrast to chromoblastomycosis)
  • Clinical triad:
    • Localized swelling
    • Underlying sinus tract
    • Grains and granules (“sulfur granules”) within the sinus tracts
  • May spread via lymphatics in a sporotrichoid pattern

Comparison of eumycetoma and actinomycetoma

Eumycetoma Actinomycetoma
Location Africa and India Latin America
Patients 20 to 40 years old 40 to 50 years old
Distribution Predominantly feet
Progression Less aggressive More aggressive
Clinical features Few fistulae with proliferative sinuses, late bone involvement with large bone cavities Many fistulae with flat sinuses, early bone involvement with small bone cavities

Differential Diagnosis

Diagnosis

  • Specimen collection
    • Send granules in sterile container
    • Can do skin scraping in areas of moist or broken skin
    • Skin biopsy
  • Histology/microscopy
    • Gram stain a crushed granule for bacteria
  • Culture
    • Set up cultures for bacterial and fungal culture

Management

  • May need imaging to assess severity and help plan management2
    • Ultrasound is the most commonly used
    • CT and MRI may also be helpful
  • Actinomycetoma can be managed medically
  • Eumycetoma is more difficult to treat, and usually requires medical management for months to a year, followed by wide local excision of the lesions
    • Antifungals should be targetted to the causative organism, or empirically against Madurella mycetomatis
    • Recommended empiric treatment is with itraconazole 200 to 400 mg/day for 6 to 9 months
    • Can also try ketoconazole 400 to 800 mg/day for 9 to 12 months or terbinafine
    • Treatment shrinks but does not necessarily cure the lesions

Further Reading

References

  1. ^  Wendy W. J. van de Sande, Ahmed H. Fahal. Graeme N. Forrest. An updated list of eumycetoma causative agents and their differences in grain formation and treatment response. Clinical Microbiology Reviews. 2024;37(2). doi:10.1128/cmr.00034-23.
  2. ^  Wendy W. J. van de Sande, Ahmed H. Fahal, Michael Goodfellow, El Sheikh Mahgoub, Oliverio Welsh, Ed E. Zijlstra. Todd Reynolds. Merits and Pitfalls of Currently Used Diagnostic Tools in Mycetoma. PLoS Neglected Tropical Diseases. 2014;8(7):e2918. doi:10.1371/journal.pntd.0002918.