Mycetoma: Difference between revisions

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* Chronic progressive granulomatous infection of the skin and subcutaneous tissue, usually affecting a single extremity
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* Chronic progressive granulomatous implantation infection of the skin and subcutaneous tissue, usually affecting a single extremity
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* Caused by either fungi or fungal-like bacteria
   
 
== Background ==
  
== Background ==
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** ''[[Actinomadura pelletieri]]'' (grains are red to pink)
  
** ''[[Actinomadura pelletieri]]'' (grains are red to pink)
   
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== Clinical Presentation ==
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=== Epidemiology ===
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* Present worldwide between 15ºS and 30ºN
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* Within Latin America, Mexico has the highest incidence
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* Also relatively high incidence in Chad, Ethiopia, India, Mauritania, Senegal, Somalia, Sudan, Yemen, and Venezuela
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* More common in poorer, rural communities
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  +
== Clinical Manifestations ==
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* Chronic implantation fungal infection characterized by swelling and draining sinuses
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* Can involve deeper tissues such as muscle or bone (in contrast to [[chromoblastomycosis]])
 
* Clinical triad:
  
* Clinical triad:
 
** Localized swelling
  
** Localized swelling
 
** Underlying sinus tract
  
** Underlying sinus tract
 
** Grains and granules (“sulfur granules”) within the sinus tracts
  
** Grains and granules (“sulfur granules”) within the sinus tracts
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* May spread via lymphatics in a sporotrichoid pattern
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  +
=== Comparison of eumycetoma and actinomycetoma ===
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{| class="wikitable"
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! !! Eumycetoma !! Actinomycetoma
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|-
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| Location || Africa and India || Latin America
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|-
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| Patients || 20 to 40 years old || 40 to 50 years old
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|-
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| Distribution || Predominantly feet ||
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|-
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| Progression || Less aggressive || More aggressive
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|-
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| 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
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|}
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  +
== Differential Diagnosis ==
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* [[Spororichosis]]
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* [[Yaws]]
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* [[Non-tuberculous mycobacteria]]
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* [[Tuberculosis]]
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* [[Osteomyelitis]]
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* [[Treponema pallidum|Syphilitic osteitis]]
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* Neoplasms, including [[Kaposi sarcoma]], fibroma, neurofibroma, malignant melanoma, fibrolipoma, osteosarcoma, rhabdomyosarcoma, osteogenic sarcoma
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* Other non-infectious causes, including foreign body granulomatous reaction and bone cysts
   
 
== Diagnosis ==
  
== Diagnosis ==
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* Specimen collection
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* Send granules in sterile container
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** Send granules in sterile container
⚫
* Gram stain a crushed granule for bacteria, then set up cultures for bacterial and fungal cultures
  
  +
** 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 management[[CiteRef::reynolds2014me]]
  +
** Ultrasound is the most commonly used
  +
** CT and MRI may also be helpful
  +
* Actinomycetoma can be managed medically
  +
** Standard treatment is [[Is treated by::trimethoprim-sulfamethoxazole]] 48 mg/kg per day for 5 weeks followed by [[Is treated by::amikacin]] 15 mg/kg daily divided q12h for 3 weeks, followed by a 2 week interval, then repeated until cured (usually four cycles)
  +
*** May substitute [[Is treated by::amoxicillin-clavulanic acid]] for the trimethoprim-sulfamethoxazole
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*** Rescue therapies substitute in a carbapenem for the trimethoprim-sulfamethoxazole
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** Can also try combination [[Is treated by::trimethroprim-sulfamethoxazole]] plus either [[Is treated by::dapsone]] or [[Is treated by::streptomycin]]
  +
* 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 [[Is treated by::itraconazole]] 200 to 400 mg/day for 6 to 9 months
  +
** Can also try [[Is treated by::ketoconazole]] 400 to 800 mg/day for 9 to 12 months or [[Is treated by::terbinafine]]
  +
** Treatment shrinks but does not necessarily cure the lesions
  +
  +
== Further Reading ==
  +
* Mycetoma: a unique neglected tropical disease. ''Lancet Infect Dis''. 2016;16(1):100-112. doi: [https://doi.org/10.1016/S1473-3099(15)00359-X 10.1016/S1473-3099(15)00359-X]
   
 
[[Category:Skin and soft tissue infections]]
  
[[Category:Skin and soft tissue infections]]

Latest revision as of 19:53, 14 July 2020

  • 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 management1
    • 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, 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.

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