Mycetoma in South India: retrospective analysis of 13 cases and description of two cases caused by unusual pathogens: Neoscytalidium dimidiatum and Aspergillus flavus

Abstract

Mycetoma is a chronic suppurative and/or granulomatous inflammatory lesion of skin, subcutaneous tissue, fascia, and tendons caused by the traumatic inoculation of either fungal (eumycotic) or bacterial (actinomycotic) organisms present in the soil. The disease is characterized by triad of tumefaction, discharging sinuses, and grains. Thirteen new cases of biopsy proven mycetomas were analyzed, retrospectively, from January 2000 to October 2009. Clinical parameters, bone involvement, microbiological properties, and histopathological features were evaluated. Categorization into eumycotic or actinomycotic was based upon features on hematoxylin and eosin stained sections with special stains. Therapeutic outcome was presented wherever available. There were eight actinomycetomas and five eumycetoma cases including 11 men and two women. Foot and lower extremities were the most common site of involvement (9 of 13, 69%). Culture results were available in 8 of 13 cases (61.5%). Madurella mycetomatis, Neoscytalidium dimidiatum, and Aspergillus flavus were the isolates among eumycetomas whereas Acinomadura madurae, Actinomadura pelletieri, and Nocardia species were the isolates among actinomycetomas. Two cases had underlying bone involvement. On follow-up, four of five eumycetoma cases showed partial improvement following surgery and antifungal therapy, one had amputation of the lower leg. Of the actinomycetomas, six of eight had dramatic improvement following sulfamethoxazole-trimethoprim based therapy, one had complete cure, and one was lost to follow-up. Strong clinical suspicion, exact categorization of lesion into eumycotic or actinomycotic along with culture correlation, is essential for prognosis and effective therapy.