1
THE NATIONAL ALREBAT UNIVERSITY
Faculty of Post Graduate Studies
Characteraization of Foot Mycetoma Using
Utrasound
ةتوصيف مرض مايستوما القدم بالموجات فوق الصوتي
Research Submitted For partial fulfillment of Requirements of
the MSC Degree in Medical Diagnostic Ultrasound
By:
Osama Abdullah Mohamed Abbas
Supervisor:
Dr:Elser Ali Said Taha
2016
I
أآلية
ٹ ٹ
چژ ڑ ڑ ژڈچ
١القلم:
II
Dedication To my father
my mother
my brothers
My sisters
And
My friends
III
aKnowledge
First and above all, thanks and praises to Allah, the almighty for
providing me this opportunity and granting me the capability to
proceed successfully, and the prayers and peace be upon the
merciful prophet Mohamed.
I want to express my sincere thanks and deep graduate to my
faithful supervisor Dr.Elser Ali Said for his guidance
throughout this thesis and sharing his knowledge through the
entire study.
I would also like to thanks Dr.Ahmed Abdulraheem to support
meand sharing his knowledge.
My thanks also to The staff of ultrasound department of Soba
University hospital, especially Dr.Mustafa Alameen
I would also like thanks toDr.Safa Abdulrhman to support
methrough the entire study.
.
IV
Abstract
This study is Cross section descriptive hospital based study done inSoba
university hospital in Khartoum state in period from November 2015 to October
2016,Using hight quality ultrasound machine type Cavan General TISO
ultrasound machine using linear high frequency transducer (7.5- 10
MHz)tocharacterize mycetoma using ultrasnography.
Atotal of 50 patients their ages ranging between 8 to 55 years suffering from the
foot mycetoma . Most of the patients used in this study had undergone routine
plain x-ray before coming for ultrasound examination.
The main finding of this study show the foot mycetoma more common in
males (72%) than females and the Most common affected age between( 24-31
years, mean 27.5 years) duo to the major of the patients were workers . The
type of mycetoma shows fungal type (80%) more common than bacterial
type.
This study shows most common ultrasound appearance of mycetoma with no
grain (66%),not found pockest of fluid collection (74%) due to surgical
treatment and it was found that no intact to the bones (66%) especially in the
fungal type. All features of the grains are present with the two types (bacterial
and fungal ) and the ultrasound examniation able differntiate between two
types.
This study showed that the most common patients affected by mycetoma in
Sudan from Aljazeera state (38%) and Senar state (36%), also the Rt foot most
common sites affected by mycetoma than left foot.
V
ملخص البحث
ففي بمستشفف سفابا المفامعي با يفة المر فا جريف أقائمة في المستشفف مستعرضة دراسة وصفية هذه
عفففالي ال قفففة جهفففاو ماجفففاص ففففا صفففا ية باسفففتم ا 2016كتفففابر ا حتففف 2016 مفففار الفتفففرن مففف
بغففر ميغفاهير 10الفف 7.5مسففرار عفالي التففردد ق ر ف (باسفتم ا Cavan TISO General)نفا
. دراسة خصائص ظهار مر المادورا
جمفيعهم كفانا يعفانان مف مفر ( سنة55-8تتراوح اعمارهم ما بي )مريض 50جري هذه ال راس عل أ
قرل فحص الماجاص شعة رو ينية سابقة أجري لهم فحاصاص أمعظم المرض في هذه ال راسة الق دوراما
الصا ية. فا
%( مقارنففة بالنسففاظومعظم ارعمففار 72أكثر شففياعا عنفف الرجففا )القفف م ادوران مففأنتففائه هففذه ال راسففة هففم أ
وذلفففن ن معظفففم المصفففابي مففف ال رقفففة سفففنة( 27.5, متاسففف سفففنة 24-31)المصفففابة تفففراوح بفففي
كثر شياعا م النا الركتيري .أ%( 80ن النا الف ري )أظهرص ال راسة أالعامل .
ن معظففم خصففائص ظهففار المففادورا فففي الماجففاص الفففا صففا ية بفف ون حريرففاص أأظهففرص هففذه ال راسففة
صففا بففالعظم أيضففا نمفف ها بفف ون أ%( وذلففن نسففرة للعففرا المراحففي و74) %( , بفف ون ممففو سففاائل 66)
%( وخاصففة فففي النففا الف ففري . كففل خصففائص الحريرففاص نمفف ها فففي النففاعي )الركتيففري والف ففري( 66)
الماجاص فا الصا ية قادر عل التفريق بي الناعي . فحصنأو
و ية ثم%( 38و ية الم يرن ) م بالسادان أغلب المرض المصابي بالمادوراأن أوضح هذه ال راسة
صابة بالمادورا م الق اليسرى .ايضا أن الق اليمن أكثر أو %(36سنار )
VI
List of Tables
Tables No Subjects Page No
4-1 Gender percentage and frequancy 33
4-2 Age distrubuation 34
4-3 Residence percentage and frequancy 35
4-4 Side percentage and frequancy 36
4-5 Type percentage and frequancy 37
4-6 Presence of grain percentage and frequancy 38
4-7 Fluid percentage and frequancy 39
4-8 Bone effects percentage and frequancy 40
4-9 Features of the grain type crosstabulation 41
4-10 Features of fluid level crosstabulation 42
4-11 Features of effect on bone crosstabulation 42
VII
List of Figures
Figure No Subject No
2-1 Normal tibialis anterior tendon superficial to the talus and tibia 5
2-2 Foot mycetoma
8
2-3 Surgical specimen showing extensive fibrosis and multible grains
17
2-4 Ultrasound technique dorsal aspect (longutdinal)
17
2-5 Ultrasound technique dorsal aspect (transverse )
18
2-6 Ultrasound technique planter aspect (transverse)
18
2-7 Ultrasound technique planter aspect (longutdinal)
19
2-8 Ultrasound technique planter aspect (transverse)
20
2-9 Ultrasound technique planter aspect (transverse)
20
2-10 Ultrasound technique planter aspect (longtudinal )
21
2-11 Ultrasound technique planter aspect (longutdinal )
21
2-12 Ultrasongraphic image eumycetoma
28
2-13 Ultrasongraphic image actinomycetoma
28
3-1 Image showing ultrasound unit used for the study. 30
4-1 Gender distribution and percentage
33
4-2 Age distribution and percentage
34
4-3 Residence distribution and percntage
35
4-4 Side distrubuion and percentage 36
4-5 Type of mycetoma distribution and percntage 37
4-6 Grains distrubuion and percentage 38
4-7 Fluid distribution and percentage 39
4-8 Bone effect distribution and pecentage 40
VIII
List of abbreviations
US Ultrasound
MTP Metatarsal phalangeal joint
FOV Extended field-of-view
P. bodyii Petriellidiumbodyii
N. cavae Nocardiacavae
N. asteroid Nocardia asteroid
A. Madurae Actinomaduramadurae
A. pelletieri actinomaduraPelletieri
A. Flavus Aspergillusflavus
S. somalies Streptomyces somaliens
M.mycetomatis Madurellamycetomatis
M .grisea Madurellamycetomaties
CT Computed tomography
MRI Magnetic resonance imaging
T1 W image T1 weighted image
T2 W image T2weighted image
IX
List of Contents
NO Topic page No I أآلية
Dedication II
Acknowledgement III
Abstract(English) IV
Abstract(Arabic) VI
List of tables VII
List of figures IX
List of abbreviation XII
List of contents
CHAPTER ONE
1-1 Introduction 1
1-2 Problem of the study 3
1-3 Objectives 3
1-3-1 General objective 3
1-3-2 Specific objectives 3
1-4 Hypothysis 3
1-5 Justifications 3
CHAPTER TWO
2-1 Ultrasound anatomy of the foot 4
2-1-1 Tendons 5
2-1-2 Ligaments 6
2-1-3 Nerves 6
2-1-4 Capsular and fascia 6
2-1-5 Cortical bone 6
2.1.6 Articular cartilage 6
2.1-7 Muscles 7
2-1-8 Fluid and synovium 7
2-2 Foot maycetoma 8
2-2-1 Background 9
2-2-2 Frequency 9
2-2-3 Age 10
2-2-4 Sex 10
2-2-5 Causes and symptoms 10
2-2-6 Physical 11
2-2-7 Epidemiology 11
2-3-8 Type of mycetoma 12
2-2-8-1 Eumycetoma (fungal type) 12
X
2-2-8-2 Actinomycetoma (bacterial type ) 12
2-2-9 Causative species 13
2-2-10 Color of grain (granules) in mycetoma 13
2-2-11 Prognosis 13
2-2-12 Surgical care 14
2-2-13 Prevention 14
2-2-14 Diagnosis 14
2-2-15 Differential diagnosis of foot mycetoma 15
2-3 Diagnostic ultrasound of the foot 16-17
2-3-1 Ultrasound technique of the foot 17-21
2-3-2 Ultrasound appearance of foot mycetoma 22-23
2-4 Other imaging studies of mycetoma 24
2-4-1 Bone radiography 25
2-4-2 CT scan 25
2-4-3 MRI scan 26
2-5 Previous studies 26-28
CHAPTER THREE
3-1 Study design 29
3-2 Study area 29
3-3 Duration of the study 29
3-4 Study sample 29
3-5 Study varibles 29
3-6 Equipment 29-30
3-7 Ultrasound Technique 30
3-8 Image intepreting 30
3-9 Data analysis 31
3-10 Ethical considration 32
CHAPTER FOUR
4 Results 33-42
CHAPTER FIVE
5-1 Discussion 43-44
5-2 Conclusion 45
5-3 Recommendations 46
5-4 References 47
APPENDIX
Appendix 1 Images
Appendix 2 Data collection sheet
1
Chapter One
1-1 Introduction :
Mycetoma is a chronic, specific, granulomaous, progressive inflammatory
disease; it usually involves the subcutaneous tissue, most probably after traumatic
inoculation of the causative organism. Most often affected the foot or the hand .
infected normally start in the foot or the hand and travel up the leg or arm . foot is
most commonly affected.(1)
Mycetoma may be caused by true fungi (eumycetoma) or by higher bacteria
(actinomycetoma) and hence it is usually classified in to eumycetoma and
actinomycetoma respectively .Distinction between eumycetoma and
actinomycetoma is very important for the treatment.(2)
The painless subcutaneous mass, local swelling, multiple sinuses and purulent or
seropurulent discharge that may contain grains is characteristic of mycetoma.
discharging grains is during the active phase of the disease .it usually spread
involve the skin and the deep structure resulting in destruction, deformity and loss
of function , occasionally it could be fatal.(2)
Ultrasound is very accurate in the diagnosis of foot mycetoma and even in
differential diagnosis of its types; it is play a prime role in the diagnosis of this
disease which usually res Ultrasound continues to be one of the most important
diagnostic tools which used by a wide range of healthcare professional across many
applications. Ultrasounds not only complement the more traditional approaches
such as X-Ray, but also possess unique characteristics that are advantage in
2
comparison to other competing modalities such as X-Ray, computed Tomography
(CT), Radionuclide emission tomography, and MRI .(1)
The simple, noninvasive, quick, reproducible and acceptable to patient are strong
factors favoring ultrasound as screening methods. (1)
The previous studies reported the accuracy of ultrasound in diagnosis of
mycetoma was 92% and the accuracy of the diagnosis of bacterial types was 94%
and for fungal types was 90 % , commonly affected adults aged between 20-40
years predominantly males, especially agricultural workers (hand, shoulders and
back- from carrying contaminated vegetation and other burdens) or, in individuals
who walk barefoot in dry, dusty conditions, and the ultrasonographic appearance of
grains vary in eumycetoma the grain produce nemorus sharp hyper reflective
echoes in actinomycetoma the finding similar but hyper reflective echoes fine.(2)
3
1-2 Problem statement :
Mycetoma is a common problem, it is endemic in many tropical and subtropical
areas and it is reported throughout the globe and Sudan seems to be the mycetoma.
1-3 Objectives:
1-3-1 General Objective:
To characterize foot mycetoma by using ultrasound.
1-3-2 Specific Objectives:
To describe the sonographic appearance of the foot mycetoma (echogencity ,
presence and features of the grain, fluid level and effect on bone ).
To describe characteristics of the foot mycetoma by using Doppler
ultrasound.
To differentiate between eumycetoma and actinomycetoma ultrasonically.
To determine the most common age affected by foot mycetoma.
To determine the most common type of mycetoma.
To familiarize the practice of mycetoma ultrasonography in Sudan.
1-4 Hypothysis:
The ultrasound of high accuracy in diagnosis foot mycetoma, and produce a clear
picture for soft tissues of foot that do not show up well on x-ray images
1-5 Justifications:
Mycetoma in its early phase is subcutaneous disease that does not show up well
on x-ray image, ultrasound gives clear picture of soft tissue pathology and accurate
diagnosis of mycetoma.
4
Chapter Two: Literature review
2-1 Ultrasound anatomy of the foot
Musculoskeletal ultrasound is a rapidly evolving technique that is gaining
popularity for the evaluation and treatment of joint and soft tissue diseases. A clear
understanding of normal US anatomy is required to prevent misdiagnosis and
ensure optimal patient care. The advantages of sonography include its unsurpassed
depiction of normal and pathologic anatomy, accessibility, and multiplanar
capability. Selective use of high frequency transducers and optimization of
sonographic parameters improves visualization of normal and pathologic tissue.
Comparison with the contralateral anatomic structures and dynamic scanning are
invaluable in aiding learning and interpretation of normal and pathologic features.
Advances in technology with higher frequency transducers, power and color
Doppler, and extended field-of-view (FOV) functions have facilitated the
progressive development of sonography offers a cost-effective alternative for
imaging musculoskeletal disorders in many situations.
The major soft tissues of the foot are predominantly superficial and can be assessed
with a high-frequency linear transducer. The in-plane spatial resolution and
minimal slice thickness using these probes are superior to those achieved with
clinical magnetic resonance (MR) protocols. The small footprint probes are
particularly useful to maintain constant uniform contact between the probe and
skin. Active or passive movement can be used for dynamic evaluation of all
tendons for tears, abnormal movement due to subluxation, and adhesive
tenosynovitis Interrogation with color or power Doppler imaging is performed if
tendon abnormality is seen. Power and color Doppler vascularity within a tendon
or the soft tissues usually indicates tendinopathy or synovitis.(3)
5
2-1-1Tendons:
Tendons are better visualized with US than with MR imaging (MRI). Tendons
consist of bundles of linear arranged fibrils of type I collagen with a supporting
matrix. The fibrils are oriented in a direction specific to the forces applied from the
interaction between a tendon and its muscle and skeletal attachment during
movement, tendons shorten and lengthen as springs do, transmitting and absorbing
forces. When the US beam is perpendicular to the tendon, the energy of the beam
is reflected back to the transducer resulting in a fibrillary pattern of alternating
hyperechoic and hypoechoic lines. The fibrillary pattern is unique to tendons. If the
beam loses this perpendicular orientation, the beam is reflected away from the
transducer and the tendon will appear hypoechoic within a hyperechoic Parthenon.
This phenomenon is known as anisotropy and can be avoided by keeping the beam
perpendicular to the tendon.(3)
Figure 2-1: Normal tibialis anterior tendon (arrows) superficial to the talus and tibia (3)
6
2-1-2Ligaments:
Ligaments also contain longitudinally arranged parallel fibers of collagen.
However, their architecture is not as fibrillary. Although anisotropy is observed, it
is not a prominent imaging feature, but it can be used to find ligaments and
distinguish them from surrounding connective tissue. (3)
2-1-3Nerves:
Peripheral nerves can also be accurately identified using US imaging. Nerves
are composed of multiple axons that are bundled together in neuronal fascicles.
The fascicles are held together by loose connective tissue. Normal peripheral
nerves typically appear as echogenic fascicular structures and tend to be slightly
less echogenic than tendons or ligaments. This appearance is somewhat variable
depending on the location and orientation of the nerve but can usually be identified
by the nerve distribution. (3)
2-1-4Capsular and fascia:
Capsular tissue and fascia appear hyperechoic.(3)
2-1-5 Cortical bone:
Cortical bone is hyperechoic, reflecting the insonating beam and producing a
black acoustic shadow; hence, precluding visualization of the osseous medulla.(3)
2-1-6 Articular cartilage:
Hyaline articular cartilage is anechoic and homogenous and can only be
visualized in areas free of acoustic shadowing from neighboring bony structures
among them, the dorsal articular surfaces of most of the forefoot and midfoot
joints.(3)
7
2-1-7Muscle:
Muscle, like tendons and ligaments, has an organized structure. The epimysium
is identified as an echogenic envelope surrounding the muscle belly, whereas the
perimysium, enveloping muscular fascicles, is seen as short echogenic lines or dots
on a hypoechoic background.(3)
2-1-8 Fluid and Synovium:
Bland uncomplicated fluid and synovium appear uniformly anechoic. Posterior
acoustic enhancement, the absence of vascularity on Doppler imaging, and the
swirling movement of debris on intermittent pressure with the probe may
differentiate simple fluid from synovium. (3)
8
2.2 Foot mycetoma:
Mycetoma, or Maduromycosis, is a slow-growing bacterial or fungal infection
focused in one area of the body, usually the foot. For this reason – and because the
first medical reports were from doctors in Madura, India – an alternate name for
the disease is Madura foot. The infection is characterized by an abnormal tissue
mass beneath the skin, formation of cavities within the mass, and a fluid discharge.
As the infection progresses, it affects the muscles and bones; at this advanced
stage, disability may result. (1)
Figure 2.2: Foot mycetoma.(1)
9
2.2.1 Background:
Gill first described the disease in the Madura district of India in 1842, hence the
term Madura foot. In 1860, carter named the condition mycetoma , describing its
fungal etiology. In 1913 , Pinoy described the mycetoma produced by aerobic
bacteria that belong to the actinomycetoma group and classified mycetomas as
those produced by true fungi (eumycetoma ) versus those due to aerobic bacteria
(actinomycetoma). Both types have similar clinical findings.(1)
It is characterized by tumefaction, abscess formation, and fistulae. It typically
affects the lower extremities , but it can occur in almost any region of the body .
Mycetoma predominately occurs in farm workers, but it can also occurs in the
general population.(1)
Mycetoma is most common in persons aged 20-50 years. Mycetoma has male-to-
female ratio of 183:81. In Sudanese hospitals, at least 300-400 patients are
diagnosed with mycetoma every year. (1)
There are more than 30 species of bacteria and fungi that can cause mycetoma.
Bacteria or fungi can be introduced into the body through a relatively minor skin
wound. The disease advances slowly over months or years, typically with minimal
pain. When pain is experienced, it is usually due to secondary infections or bone
involvement. Although it is rarely fatal, mycetoma causes deformities and potential
disability at its advanced stage. (1)
2.2.2 Frequency:
In Sudanese hospitals, at least 300-400 patients are diagnosed with mycetoma
every year. (1)
10
2.2.3 Age:
Mycetoma is most common in persons aged 20-50 years .(1)
2.2.4 Sex:
Mycetoma has a male-to-female ratio of 183:81. (1)
2.2.5 Causes and symptoms:
Owing to wound, bacteria or fungi gain entry into the skin. Approximately one
month or more after the injury, a nodule forms under the skin surface .The nodule
is painless, even as it increases in size over the following months. Eventually, the
nodule forms a tumor, or mass of abnormal tissue. The tumor contains cavities
called sinuses that discharge blood or pus-tainted fluid. The fluid also contains tiny
grains, less than two thousandths of an inch in size. The color of these grains
depends on the type of bacteria or fungi causing the infection.(4)
As the infection continues, surrounding tissue becomes involved, with an
accumulation of scarring and loss of function. The infection can extend to the bone
, causing inflammation, pain , and severe damage , Mycetoma may be complicated
by secondary infections , in which new bacteria become established in the area
and cause an additional set of problems .(4)
Some common symptoms are Blister or bump on skin, pain in foot (feet) and pus
draining from skin. Most predisposing factors include the following; History of
trauma, walking barefoot, Agricultural work, poor personal hygiene. Poor nutrition
and Wounds or multiple infections. Patient present with painless swelling of foot
and is usually not associated with fever. (4)
11
2.2.6 Physical:
The foot is the most common site of infection; 70% of all mycetomas effect the
foot. Other reported sites of involvement include the following:
Upper extremities, Trunk, Buttocks, Eyelids, Lacrimal glands, Paranasal sinuses,
Mandible, Scalp, Neck, Perineum and Testes.(1)
2.2.7 Epidemiology:
The true incidence and the geographical distribution of mycetoma throughout the
world is no exactly known due to the nature of the disease which is usually
painless , slowly progressive which may lead to the late presentation of the
majority of patients.(2)
Mycetom has a worldwide distribution but this is extremely uneven. It is endemic
in tropical and subtropical regions. The African continent seems to have the
highest prevalence. It is found in what is known as the mycetom belt stretching
between the latitudes of 15 souths and 30 norths. The belt includes Sudan,
Somalia, Senegal, India, Yemen, Mexico, Venezuela, Colombia, Argentina and
others. (2)
Mycetoma infection, Madura foot or Maduromycosis, was originally described in
Sanskrit in the Vedic texts from India. The first English language accounts
occurred much later in the area of Madras (aka Chennai). (2)
The geographical distribution of the individual mycetoma organism shows
considerable variations, which can be convincingly explained on an environmental
basis . Areas where mycetoma prevails are relatively arid zones with a short rainy
season with a relative humidity. (2)
12
2.2.8 Types of Mycetoma:
2.2.8.1 Eumycetoma (fungal type):
Eumycetoma is characterized by the clinical trial of tumefaction, draining
sinuses, and granules. The disease usually begins as a painless swelling or
thickening of the skin and subcutaneous tissue. As the disease gradually progresses
over months or years, the initial lesion enlarges and eventually becomes tumorous.
The overlying skin may be smooth, depigmented, or shiny. Abscesses and sinus
tracts develop over time and may contain a serosanguineous or seropurulent
discharge, which may contain white –to-yellow or black granules. Granules are
firm 0.2-to 5-mm aggregates of organized vegetative, septet hyphae, which often
are embedded in a matrix cement substance. These granules are usually
macroscopic and are observed in the lesion tissue and in sinus tracts. The color of
the dark grains is thought to be due to melanin, host protein, and dark debris.
Regional lymphadenitis secondary to bacterial super infection of the lesion may be
present. (4)
2.2.8.2 Actinomycetoma (bacterial types):
Actinomycetomas are chronic, granulomatous, subcutaneous infections caused
by the traumatic inoculation of actinomycetes bacteria into the skin which
produces nodular lesions with draining sinuses and discharging grains.
The branching bacteria that cause actinomycosis are non-acid-fast anaerobic or
microaerophilic bacteria. These bacteria are smaller than 1mm in diameter, smaller
than eumycotic agents. On the other hand, the agents that cause actinomycetoma
are always aerobic and are sometimes weakly acid-fast. (4)
13
2.2.9 Causative species:
Species of bacteria that cause Mycetoma include:
Actinomaduramadurae, Actinomadurapelletierii, Streptomyces somaliensis and
Nocardia species .
Species of fungus that causse Mycetoma include:
Madurellamyceomatis, Scedosporiumapiospermum, Leptosphaeriasengalensis
Madurellagrisea. (1)
2.2.10 Color of Grain (Granules) in Mycetoms:
In Eumycetomas: Black grains is the Madurellamycetomatis and the Pale grains
are Petriellidiumboydii, Aspergillusnidulans and Aspergillusflavus.(2)
In Actinomycetomas: Red grain is the Actinomadurapelletieri , the Yellow grains
is the Streptomyces somaliensis and the pale grains are Nocardiabrasiliensis ,
Ncavae , N asteroides , Actinomaduramadurae.(2)
2.2.11 Prognosis:
Recovery from mycetoma may take months or years and the drug therapy can
reduce the chances of a re-established infection. The extent of deformity or
disability depends on the severity of infection; the more deeply entrenched the
infection, the greater the damage. By itself, mycetoma is rarely fatal, but secondary
infections can be fatal. (1)
14
2.2.12 Surgical Care:
Treatment in the past has included amputation of the affected limb or other
radical surgery. Although surgical treatment alone results in recurrence rates as
high as 80%. Surgical resection with a wide surgical margin of uninfected tissue
may be useful in early, small lesions without bony involvement. Surgical
debunking together with oral antifungal or antibacterial treatment may be
necessary with chronic extensive lesions. (1)
Fig 2-25 surgical specimen showing extensive fibrosis and multible grains.(1)
2.2.13 Prevention:
Mycetoma is a rare condition that is not contagious. (1)
2.2.14 Diagnosis:
Diagnosis of mycetoma is usually accomplished by radiology, ultrasound or by
fine needle aspiration of the fluid within an afflicted area of the body. It depends
upon isolating the causative organism along with knowledge of local endemic
infection. (1)
15
2.2.15 Differntial diagnosis of foot mycetoma:
Differential diagnosis the main differential diagnoses are chronic bacterial
osteomyelitis, tuberculosis, or the early phase of Buruli ulcer. Other deep fungal
infections such as blastomycosis or coccidomycosis.
Leishmaniasis, yaws and syphilis should be considered.Investigations Microscopy
and culture of exudates, and skin biopsy for pathology are necessary to identify the
causative organism.
Serology can be helpful with diagnosis or follow-up care during medical
treatment. (4)
16
2.3 Diagnostic ultrasound of the Foot:
Ultrasound is a non-invasive, non-painful technique performed with high
frequency sound waves, unable to be heard by the human ear. Real time images of
soft tissue and bone structures in the foot are obtained as the sound waves bounce
off these structures, and the echoes are interpreted as image on a video screen.(5)
The quality of the images obtained using ultrasound is highly dependent on the
skill of the person (ultrasonographer) performing the exam and patient body habits.
Larger patients may have a decrease in image quality due to sound wave
absorption in the subcutaneous fat layer. This results in fewer sound waves
penetrating to organs and reflecting back to transducer ultimately causing a poorer
quality image. (5)
Ultrasound is usually used in the diagnosis of soft tissue problems such as: Soft
tissue masses, Madura foot, Foreign bodies, Sprains, Neuromas, Tarsal tunnel
syndrome and to guide injections. (5)
Ultrasound is very helpful when looking at retained foreign bodies not observed
on plain films and when looking for soft tissue abscesses. Abscesses are observed
as complex and typically cystic structures containing internal echogenicity with
through transmission. The echogenicity varies depending on the contents of the
abscess. (5)
Ultrasound is particularly useful in the foot because it can help identify the exact
location of the abscess within the many deep compartments and facial structures. it
also detects the damage done to the organ by the fungus.(5)
Ultrasound image allows the foot specialist to confirm a diagnosis in real time,
and therefore prescribe a treatment plan faster than traditional methods. (5)
17
2.3.1 Ultrasound technique of the foot:
A-Dorsal aspect of the foot: metatarsophalangeal joint and extensor hallucis
longus tendon longitudinal.
Figure 2-4 : ultrasound technique dorsal aspect (longitudinal) (6)
B- Dorsal aspect of the foot: Interdigital space transverse
Figure 2-5: ultrasound technique dorsal aspect (transverse) (6)
18
C- Plantar approach: interdigital space transverse:
Figure 2-6: ultrasound technique planter aspect (transverse) (6)
D- Plantar aspect of the foot : Plantar fascia insertion longitudinal :
Figure 2-7: ultrasound technique planter aspect (longitudinal) (6)
19
E- Plantar aspect of the foot: Plantar fascia insertion Transverse:
Figure 2-8: ultrasound technique planter aspect (transverse)(6)
F- Planter aspect of the foot: Flexor hallucis longus tendon transverse:
Figure 2-9 : ultrasound technique planter aspect (transverse)(6)
20
G- Planter aspect of the foot: Flexor hallucis longus tendon transverse:
Figure 2-10 : ultrasound technique planter aspect (longitudinal ) (6)
21
H- Plantar aspect of the foot: Plantar fascia distal longitudinal:
Figure 2-11 : ultrasound technique planter aspect (longitudinal )(6)
22
2.3.2 Ultrasound appearance of foot mycetoma:
Ultrasound is very accurate in the diagnosis of foot mycetoma and even in
differential diagnosis of its types. An ultrasound appearance a hypoechoic lesion
containing discrete hyperechoic foci. Single or multiple thick –walled cavities with
hyper reflective echoes and no acoustic enhancement are always observed with
mycetoma, whereas these features are not demonstrated in non mycetoma
swellings.(7)
In eumycetoma, the hyper reflective echoes are sharp, corresponding to the
grains in the lesion. In actinomycetoma, the hyper reflective echoes are fine and
closely aggregated and commonly settle at the bottom of the cavities, In bacterial
types , in most cases capsule like outline found around the lesion where as in
fungal no capsule is seen.(7)
The ultrasound appearances were initially described by Fahal et al ., who
demonstrated on in vitro imaging of the mycetoma lesions that the hyper-reflective
echoes corresponded to the grains ; eumycetoma grains produce sharp
hyperrechoiec foci , while actinomycetomas produce fine hyperechoic foci that
commonly settle at the bottom of the rounded lesions.(7)
The mycetoma grains, their capsules, and granulomas have characteristic
ultrasonographic appearances. According to Fahal et al, ultrasound could be used
to differentiate eumycetoma from actinomycetoma . In eumycetoma, the grains
produce numerous, sharp, hyper reflective echoes, and there are single or multiple
Thick-walled cavities with no acoustic enhancement.
In actinomycetoma , the findings are similar but the hyper reflective echoes are
fine , closely aggregated , and commonly settle at the bottom of the cavities.(7)
23
The use of color flow Doppler studies provides a wide information about
differential diagnosis of foot mycetoma.(7)
Figuer 2-12 ultrasongraphic image of actinomycetoma .(7)
Figure 2-13 Ultrasongraphic image eumycetoma .(7)
24
2.4 Other imaging studies of Maycetoma :
2.4.1 Bone radiography:
Plain x-ray is used to assess the evidence of bone involvement. Only 3% of
patients have normal radiographs. The bones are almost always attacked from the
outside, In contrast to bacterial osteomyelitis. Radiographic classification of bone
involvement (stages 0-6) has been suggested. A few radiographic bone changes
have been described that help distinguish between actinomycetoma and
eumycetoma.(8)
Eumycotic lesions tend to form a few cavities in bone that are >1 cm in
diameter, while actinomycetes often form smaller but more numerous cavities,
leading to a moth-eaten appearance. (8)
Once mycetoma has invaded the bone, the following changes may be observed:
1- Cortical thinning is due to compression from the outside by the mycetoma
2- Cortical hypertrophy or periosteal proliferation may present as a sunray
appearance and a Codman triangle.
3- Multiple lytic lesions or cavities may be large and few in number with well-
defined margins (eumycetoma) or small and numerous with ill-defined
margins (actinomycetoma)
4- Disuse osteoporosis may occur in late stages mycetoma.(8)
Bone involvement has been radiographically classified, as follows:
Stage 0 - Soft tissue swelling without bone involvement
Stage 1- Extrinsic pressure effects on the intact bones in the vicinity of an
expanding granuloma
25
Stage 2- Irritation of the bone surface without itraosseous invasion
Stage 3- Cortical erosion and central cavitations
Stage 4- Longitudinal spreading along a single ray
Stage 5- Horizontal spreading along a single row
Stage 6- Multidirectional spread due to uncontrolled infection.(8)
2.4.2 CT scan:
CT finding in mycetoma is not specific but is helpful in the early stages and
provides better delineation of the bone changes than radiograph. (8)
2.4.3 MRI scans:
MRI of mycetoma lesions is helpful in visualization of the extension of bone
destruction and soft tissue involvement it can provide a better assessment of the
degree of bone and soft- tissue involvement and may be useful in evaluating the
differential diagnosis of the swelling.( 8)
MRI usually shows multiple 2-5 mm lesions of high signal intensity which
indicates the granuloma interspersed within a low-intensity matrix which is the
fibrous tissue. The dot-in-circle sign which indicates the presence of grains is
characteristics of mycetoma and it’s highly specific. The differential diagnosis of
mycetoma MRI is chronic oestomyelitis, granulomas, soft tissue tumors, bone
tuberculosis and cold abscesses.(8)
Initial reports of the MRI findings of mycetoma described lesions with low signal
on T1W and T2W images, which assumed to be due to susceptibility from the
metabolic products of the grains. Correlating the MRI and histological findings,
they suggested that the high-signal areas seen on MRI represented inflammatory
26
granulomata, the low-intensity tissue seen surrounding these lesions represented
the fungal balls or grains. They proposed that it is likely to be a highly specific sign
for mycetoma. (8)
27
2.5 Previous studies:
Sonographic presentation and Differential Diagnosis of Mycetoma (Madura
foot) in study by Qureshi Mohammed Ali, Syed Amir Gilani, Elreyah Mustafa
July 2009
After ultrasound guided aspiration, the pathological material from all 50 patients
was sent for cytological examination. The lab tests confirm the diagnosis of 46
(92%) cases as mycetoma . te accuracy for diagnosis of bacterial types was 94%
and for fungal types 90% . Sonographic presentation by gray scale show jelly like
hypo to anechoic mass with rounded or oval hyperechoic granular structures which
move or float at real time. In fungal type fluid contents are as compared to other
type, in some types we can see the halo around the hyperechoic sticks (granules) in
the fungal type. In bacterial types , in most cases a capsule like outline is seen
around the lesion where as in all cases diagnosis as fungal no capsule is seen By
color Doppler: show signs of the hyperemia are present more flow is seen. in
bacterial types as compared to fungal types.
Characterization of Mycetoma Using ultrasound, Amna Abaas, Alzayem
ALAzhary University march 2013
This study carried out in Soba University hospital in Khartoum state, Atotal of 100
patients , the main finding shows the foot mycetoma more common in male (76%)
, most common affected age intervals (21-30) years 34% , and (31-40)years 32% ,
the most common area from Aljazeera state (57%) and the fungal type (78%) is
more than bacterial type (22%) . the study revealed that the major of the patient
were workers (61%) the type of mycetoma were (22%) actinomycetoma and
(78%) eumycetoma .
28
Ultrasonographic Imaging of Mycetoma In study by Fahal .A.H,sheik HE,
Homeida MM , Arabi YE, Mahgoub Es, Br J Surg . Aug 1997
The mycetoma grains. Their capsules and the accompanying inflammatory
granulomas have characteristic ultrasonographic appearances. In eumycetoma
lesions , the grains produce numerous , sharp hyper-reflective echoes and there are
single or multiple thick –walled cavities with no acoustic enhancement .In
actinomycetoma , the findings are similar but the hyper-reflective echoes are fine,
closely aggregated and commonly settle at the bottom of the cavities . None of the
non-mycetoma foot swellings (which included lipoma, ganglion, foreign body
granuloma and others) studied had these features.
Correlation of ultrasonographic features of different types of mycetoma to the
laboratory diagnosis in Sudanese patients in mycetoma research center in
Suba university hospital in studay by Dr. Abdalla mohammed abdulla June
2010
Of the total, ultrasonography diagnosed eumycetomain 81 patients (81%) and
actinomycetoma in 19 patients (19%). The histopathologic specimens confirmed
the ultrasound diagnosis for eumycetomas in 72 patients and the diagnosis of
actinomycetoma in 17 patients, with accuracy of 84.9% for eumycetoma and
89.4% for actinomycetoma.
29
Chapter Three: Methodology
3-1 Study design:
This was non-interventional descriptive Cross section hospital based study to
characterize the role of ultrasound in diagnosis of foot mycetoma .
3-2 Study area:
Soba university hospital in Khartoum state
3-3 Duration of the study:
15 November 2015 – 15 October 2016
3-4 Study sample:
Selection random number of patient (50 patients) age from 8-55 years with
history of foot mycetoma.
3-5 Study variables:
Patients demographics data and ultrasound findings, type of mycetoma, type of
grain, effects on bone, fluid level.
3-6 Equipment:
Machine: Cavan General TISO ultrasound machine using linear high frequency
transducer (7.5- 10 MHz).
30
Figure 3.1. Image showing ultrasound unit used for the study.
3-7 Ultrasound technique for foot :
First the researcher begins the ultrasound scan and then the Ultrasonographer to
confirm the diagnosis. Always begin by the affected area then make scan for the
whole foot from forefoot to heel to check the disease prognosis. Ultrasonographer
wear gloves to prevent the contagious. (9)
3-7-1 Hind foot:
Planta fascia: patient prone on bed, foot flexed with toes on the bed for support.
Place the probe over the midline of the heel on the plantar aspect. The toe of the
probe towards the heel. Scan in longitudinal and transverse over the plantar aspect
31
of the metatarso-phalageal joints. Scan the plantar fascia distal longitudinal and
transverse Flexor hallucis longus tendon transverse and longitudinl. The plantar
fascia appear as a fibrillar structure inserting onto the calcaneum . It should be flat
and homogenous (9)
3-7-2 Mid foot
Follow the plantar fascia into the arch and look for fusiform, nodular thickening.(9)
3-7-3 Forefoot
Each metatarso-(phalangeal joint scan in different position to assess the extensor
then flexor. (9)
3-7-4 plantar plates
Scan in longitudinal over the plantar aspect of the metatarso-phalangeal joints. The
plantar plate is readily seen as a homogeneous elongated wedge arising from the
base of the proximal phalanx extending under the head of the metatarsal .(9)
3-8 Image interpreting:
Mycetoma appear hypo echoic lesion contain hyper echoic foci, in the
eumycetoma the grains give sharp hyper reflective echoes, the cavities are few in
number but large in size and in the actinomycetoma grains fine hyper reflective
echoes . Cavities numerous in number but small in size.
3-9 Data analysis:
The data was analyzed by statically package for social science SPSS.
32
3-10 Ethical considerations:
All patients participate in this study was taken oral agreement, No identification of
individual details were published and no information or patient details will be used
for other reasons.
33
Chapter four: Results
This study includes 50 patients aged between 8-55 years all were complaining of
persistent foot Mycetoma, the results of ultrasonic examinations was as follows:
Table 4-1: Gender distribution and percentage
Gender Frequency Percent
Male 38 76.0
Female 12 24.0
Total 50 100.0
Figure 4-1: Gender distribution and percentage
0
5
10
15
20
25
30
35
40
45
50
male female
76% 24%
34
Table 4-2: Age distribution and percentage
Age Frequency Percent Mean
8-15 2 4.0 11.5
16-23 6 12.0 19.5
24-31 17 34.0 27.5
32-39 10 20.0 35.5
40-47 9 18.0 43.5
48-55 6 12.0 51.5
Total 50 100
Minmum age= 14, maximum=52, mean= 33, std=10.023
Figure 4-2: Age distribution and percentage
0
2
4
6
8
10
12
14
16
18
age 8-15 16-23 24-31 32-39 40-47 48-55
4%
12%2
34%
20%
18%
12%
35
Table 4-3: Geographical distribution in Sudan
Residance Frequency Percent
Aljazeera state 19 38.0
Senar state 18 36.0
Khartoum state 6 12.0
White nile state 4 8.0
Kordfan state 2 4.0
Revir nile 1 2.0
Figure4-3: Residence distribution and percentage
0
5
10
15
20
25
30
35
40
45
50
aljazeera senar khartoum wite nile kordfan river nile
38%
36%
12%
8%
4%
2%
36
Table 4-4: Study group affected foot side
Side Frequency Percent
Right foot 29 58.0
Left foot 21 42.0
Total 50 100.0
Figure 4-4: side distribution and percentage
0
5
10
15
20
25
30
35
40
45
50
left foot right foot
42%
58%
37
Table 4-5: Type of mycetoma distribution and percentage
Type Frequency Percent
Eumycetoma 40 80.0
Actinomycetoma 10 20.0
Total 50 100.0
Figure 4-5: Type of mycetoma distribution and percentage
0
5
10
15
20
25
30
35
40
45
50
eumycetoma actinomycetoma
80% 20%
38
Table 4-6: Type of grains
Type Frequency Percent
No grain 33 66.0
Multiple grains 13 26.0
Solitary grain 4 8.0
Total 50 100.0
Figure 4-6 grain distribution and percentage
0
5
10
15
20
25
30
35
40
45
50
no grain multiple grains solitary grain
66%
26%
39
Table 4-7: Demonstration presence and absent of fluid level
Fluid Frequency Percent
No fluid 37 74.0
Fluid collection 13 26.0
Total 50 100.0
Figure 4-7 fluid distribution and percentage
0
5
10
15
20
25
30
35
40
45
50
no fluid fluid collection
74% 26%
40
Table 4-8: percentage of bone destruction
bone Frequency Percent
No intact 33 66.0
Intact 17 34.0
Total 50 100.0
Figure 4-8: Bone effect distribution and percentage
0
5
10
15
20
25
30
35
40
45
50
intact no intact
34% 66%
41
Table 4-9: features of the grain type cross tabulation
Features of the
grain
Type of mycetoma Total
Eumycetoama Actinomycetoma
No grain
Multiple grain
Solitary grain
Total
26
7
5
40
5
4
1
10
33
11
8
50
p =0.033 significant at p= 0.05
r=0.34
42
Table 4-10: features of fluid level cross tabulation
Features of fluid
level
Type of mycetoma Total
Eumycetoama Actinomycetoma
Pocket of Fluid
collection
No Pocket of Fluid
collection
Total
8
32
40
5
5
10
13
37
50
p =0.099 significant at p= 0.05
Table 4-11: features of effect on bone cross tabulation
Features effect on
the bone
Type of mycetoma Total
Eumycetoama Actinomycetoma
Intact bone
No intact to bone
Total
8
32
40
5
5
10
13
37
50
p =0.035 significant at p= 0.05
r=0.37
43
Chapter five: Discussion, conclusion& recommendations.
5-1 Discussion:
Mycetoma was a common problem in many tropical and subtropical areas and it
has a high morbidity and can be fatal. The accurate diagnosis of mycetoma is of
great importance for proper planning and management leading to care of
mycetoma patients and reduce patients suffering.
Perhaps this is the 5th
study dealing with mycetoma by ultrasonography in Sudan;
four studies were conducted during (1997-2013).
The main finding of this study show the foot mycetoma more common in males
(72%) than females and the Most common affected age between (24-31, mean 27
years ,percentage 34%) duo to the major of the patients were workers, especially
agriculture workers in whom minor skin injries, this finding agree with previous
study done by (Abbas,Amna ,march 2013).
The type of mycetoma shows fungal type (80%) more common than bacterial
type, this same finding of all previous study done before
This study shows most common ultrasound appearance of mycetoma with no
grain (66%), not found pockets of fluid collection (74%) due to surgical
treatment and it was found that no intact to the bones (66%) especially in the
fungal type, due to long period of mycetoma. All features of the grains are present
with the two types (bacterial and fungal) and the ultrasound examination able
differentiate between two types. The characteristic ultrasonographic features it
appearance different according to its type; In eumycetoma lesions it has pocket of
the fluid collection which is smooth and well define, the grains connected with
other and produce numerous sharp hyper-reflective echoes, which are consistence
44
with grains . In actinomycetoma lesions, the findings are similar but the pocket of
the fluid collection ill define and the grains are less distinct, this due to smaller size
of the grains. This finding agree with previously study by (Fahal, A.H, et,Aug
1997).
This study showed that the most common area in Sudan the Aljazeera state
(38%) and Senar state (36%) of all cases due to most agriculture area, this finding
agree with previously study by (Fahal ,A.H, et al ,Aug 1997).
Also the Right foot most common sites affected by mycetoma than left foot.
45
5.2 Conclusions:
This was characterization study deal with the foot mycetoma ultrasonography , the
aim of this study are to familiarize the practice of foot mycetoma ultrasonography
in Sudan and to study the sonographic characterization of the foot mycetoma.
This study was take about eight months and done in Suba university hospital for
50 patients (38 males and 12 females ) aged between 8-55 years that all patients
were scanned by Cavan General TISO ultrasound machine using linear high
frequency transducer (7.5- 10 MHz).
The results of this study showed the foot mycetoma more common in males than
females , the most common affected age between (24-31 years, mean 27 years)
and the most common areas are Aljazeera state and Senar state.
The eumycetoma more common types than actinomycetoma and the right foot
most common side affected.
Ultrasound is highly effective and safe for diagnosis foot mycetoma and can
differentiate between eumycetoma and actinomycetoma.
The mycetoma grains, their capsules and the inflammatory granuloma have
characteristic ultrasonographic appearance, mycetoma appear as hypoechoic lesion
contain hyperechoic foci, single or multiple thick walled cavities with no acoustic
enhancement. In eumycetoma grain produce sharp hyperreflctive echoes, pocket of
the fluid collection is smooth and will define. In actinomycetoma the grains are
less distinct due to its smaller size and the pocket of fluid collection is ill defined.
46
5.3 Recommendations:
1-Ultrasound with high frequency transducer (7.5-10 MHz) is very effective and
accurate. It must be used as the first tool.
2-Educating and training technologist, sonographers & radiologists to perform
optimum examination and correct interpreting are of prime importance.
3-Estabilshed multiple mycetoma research center around all of the state highly
affected by mycetoma .
4-Using Full protection to staff and Always wear gloves for any internal or
external examination
5- Using the Color Doppler Ultrasound as first diagnostic tool in differential
diagnosis of types of mycetoma.
6- Another research studies should be done with expanding period of time and
include more sample data for precise and accurate results.
47
5-4 References:
1- Ahmed AA, van de sande WW, Fahal A, et al, Mangment of mycetoma major
challenge in tropical mycoses with limited international recognition opin infect
dis 2007 . p 146-51
2- Fahal AH, Sheik HE, Homedia MM. Arabi Y Mahgoub. ES, Ultrasongraphic
imaging of mycetoma, Br J Surg 1997, 84;1120-2
3- www.ncbi.nlm.nih.gov/pubmed/foot
4- Fahal AH; Mycetom : a thorn in the flesh . Trans R soc Trop med Hyg 2004 Jan
; 98 (1): 3-11. [abstract]
5- Lichon v .Khachemoune A ; mycetoma : Am J cline dermatol 2006 .P . 315-321.
6- www.ultrasoundpaedia.com/normal.foot
7-Fahal AH. Suliman SH, clinical presentation of mycetoma . 1994 32:46-66
8- Fahal AH , Mycetoma thorn on the flesh review article 2004; 98:3
9- www.ultrasoundcases.info/protocol-view.aspx
48
Appendix (1)
Ultrasound images
Image 1:24 Male RT foot actinomycetoma ill define pocket fluid
collection with small multiple echogenic grains intact bone in sole
of the foot
Image 2: RT 32 male foot with Actinomycetoma ill define pocket
fluid collection no grain, intact bone blackness and bone shadows
49
Image3: RT foot 22 years eumycetoma well-defined pockt of fluid
collection without grains
Image 4 : 30 years female RT foot residual eumycetoma multiple
small grains with foreign body in the big toe .
50
Image 5: 27 female left actinomycetoma no pocket of fluid
collection no grain intact bone blackness and bone shadows
Image 6: left foot eumycetoma with well define pocket of fluid
collection contain multiple echogenic grains
51
Image 7: 33 male foot eumycetoma with multiple garins and
multiple well define cystic pocket of fluid collection extended to the
ankle and leg
Image 8: 21 years female Lt foot eumycetoma no pocket fluid
collection no grains intact bone
52
Image 9: 15 years male Ultrasound image shows left foot
eumycetoma with large pocket of fluid collection and aggregated
grains and intact with bone
Image10: left foot eumycetoma 23 years male with well define
pocket of fluid collection contain multiple echogenic grains
53
Image 11: Ultrasound image male 40 years left foot eumycetoma
with well-defined pocket of fluid collection and aggregated grains
and intact with bone
Image 12: RT foot eumycetoma with well define pocket of fluid
collection contain multiple echogenic grains no intact bone
54
Image 13: RT foot 22 years female eumycetoma with well define
pocket of fluid collection no grains no intact bone
Image 14 RT foot eumycetoma with well define pocket of fluid
collection contain multiple echogenic grains in the dorsum of the
foot intact bone
55
Image 15 LT foot eumycetoma with well define pocket of fluid
collection contain echogenic grains no intact bone
Image 16 RT foot eumycetoma with well define large pocket of fluid
collection contain multiple echogenic grains extended to the medial
part of ankle joint no intact bone.
56
Image 17: RT foot eumycetoma with well define pocket of fluid
collection in the plantar of the foot no grains no intact bone
Image 18: Normal LT foot after surgical treatment no pocket of
fluid collection or grains .
57
Image 19 : RT foot 29 years male shows large well-defind pockt
of fluid collection contain multiple echogenic grains no intact
bone features of eumycetoma
58
Appendix (2)
Data collection sheet
National Ribat University
Colleague of graduate studies
CHARACTERAIZATION OF FOOT MYCETOMA USING
ULTRASOUND
Data collection sheet:
Patient name : Gender :
Residence : Side :
Type: Treatment:
Ultrasound features :
GRAIN
A-NO GRAIN ( ) B-MULTIBLE GRAIN ( ) C- SOLITARY GRAIN ( )
FLUID
A- No pocket of fluid ( ) B- Collection of fluid ( )
BONE EFFECT ;
A- Non intact ( ) B- intact ( )
Signature :
59
Image 21: Soba universty hospital
