Mycetoma (Madura)

BY

D. Ballal

Mycetoma Definition

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.

Description

Although the bacteria and fungi that cause mycetoma are found in soil worldwide, the disease occurs mainly in tropical areas in India,

Africa, South America, Central America, and southeast Asia. Mycetoma is an uncommon disease, affecting an unknown number of people

annually.

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.

Causes and symptoms

Owing to a 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.

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.

Diagnosis

The primary symptoms of a tumor, sinuses, and grain-flecked discharge often provide enough information to diagnose mycetoma. In the

early stages, prior to sinus formation, diagnosis may be more difficult and a biopsy, or microscopic examination of the tissue, may be

necessary. If bone involvement is suspected, the area is x rayed to determine the extent of the damage. The species of bacteria or fungi

at the root of the infection is identified by staining the discharge grains and inspecting them with a microscope.

Treatment

Combating mycetoma requires both surgery and drug therapy. Surgery usually consists of removing the tumor and a portion of the

surrounding tissue. If the infection is extensive, amputation is sometimes necessary. Drug therapy is recommended in conjunction with

surgery. The specific prescription depends on the type of bacteria or fungi causing the disease. Common medicines include antifungal

drugs, such as ketoconazole and antibiotics (streptomycin sulfate, amikacin, sulfamethoxazole, penicillin, and rifampin).

Prognosis

Recovery from mycetoma may take months or years, and the infection recurs after surgery in at least 20% of cases. 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.

Prevention(Mycetoma is a rare condition that is not contagious)

History:

Discovered by Gil in India 1842.

Madura foot

Definition

A chronic, slowly progressive granulomatous

disease of the subcutaneous tissues,

Later spreads to skin and bones.

Characterized by formation of grains (Black,

White, yellow, or Red).

Is painless unless secondary bacterial infection

occur

Is progressively destructive with loss of

function of the organ affected.

Epidemiology

The disease is common throughout the

tropical & subtropical countries.

Organisms are soil saprophytes or plant

parasites, infection is acquired exogenously

by trauma (thorn prick).

Man to man infection doesn't occur.

Any age group can be affected.

Classification

According to:

1-Colour of grains: white, black, red, yellow.

2-Causative agents:

(a) True fungi→ Eumycetoma.

(b) Higher bacteria→ Actinomycetoma.

Eumycetoma:

Caused by: e.g.

Madurella mycetomatis: commenst one > 75%

(in Sudan) big black grains.

Madurella grisea: black grains.

Aspergillus nidulans: big white grains.

Petriellidium boydii: white yellow grains.

الحبوب السوداء: المادوريلة السنجابية .

. حبوب بيضاء كبيرة: الرشاشية المعششة

Petriellidiumالبويدية:

Actinomycetoma:

Caused by:

Actinomadura madurae: big white.

Actinomadura pelletieri: small red.

Streptomyces somaliensis: small hard yellow

grains (sand grains).

Nocardia braziliensis: small white yellow.

Pathogensis

Is not known, but cell mediated immunity is

depressed.

Clinical features

Incubation very lengthy (up to 30 yrs).

Initially present with hard subcutaenous

swelling

later on discharging sinus→ coloured grains.

Host response is the formation of granuloma.

Differences between the two types:ActinomycetomaEumycetoma

Rapidly progressive.Slowly progressive

3 months→30 years.

ill defined, non capsulated

more destructive.Well demarcated &

capsulated.

Multiple sinuses.Few sinuses.

Early bone involvement.Late bone involvement.

Diagnosis

Clinical diagnosis.

Radiological diagnosis.

Laboratory diagnosis.

Laboratory diagnosis

Specimens:

Depend on the stage of presentation:

If the patient present early with subcutaenous

swelling:

a- Blood for serology.

b- Biopsy for histopathology.

If the patient present with swelling &

discharging sinuses : specimen is pus and

grains.

Direct microscopy:

Examine grains by:

Wet preparation (KoH):

Thick segmented hyphae + chlamydospores→

Eumycetoma.

Thin branching filaments→ Actinomadura→ do

Gram stain→ Gram +ve filaments. للتاكد انها بكتيريا

ولمعرفة النوع

Culture:

Grains are cultured as follow:

Eumycetoma: in Blood agar & subcultured on

sabouraud agar.

Actinomycetoma: in L.J medium then

subcultured on sabouraud agar.

Saboraud’s agar

Biopsy:

Specimens taken in formalin for histopathology.

And in normal saline for microscopy & culture.

Serology:

Very important:

Immuno diffusion.

Counter immuno electrophoresis (CIE).

Enzyme Linked ImmunoSorbant Assay

(ELISA).

Management:

Surgery & antifungal agents:

Ketoconazole.

Itraconazole.