Eumycetoma Research Articles

The foot that stalled a thousand ships: a controversial case from the 13th century BCE

The foot that stalled a thousand ships: a controversial case from the 13th century BCE

Mycetoma Leg A—Case Report

One rare and peculiar result of repeated minor trauma to the leg is Madura foot. Caused by fungi or fungus-like bacteria, Madura foot is found mainly in the tropics. A report of a classic case with chronic indurated swelling involving the leg and a discharge of yellowish granules is presented. The case is reported to highlight the fact that though Maduramycosis needs prolonged intensive antibacterial chemotherapy, even extensive disease can be successfully managed with conservative therapy.

Lymphocyte subsets, macrophages and Langerhans cells in actinomycetoma and eumycetoma tissue reaction

The aim of this work was to demonstrate, quantify and compare cell elements in the inflammatory infiltrate of 23 skin lesions of actinomycetoma (ACM) and 17 of eumycetoma (EUM). Epidermal Langerhans cells (LC) population was also analyzed in 18 ACM, 13 EUM and ten normal skin samples as control group. Tissue response in both groups of mycetoma showed CD4 and CD8 T lymphocytes surrounding the neutrophils aggregates with macrophages, revealed by CD68 antibody, among them. B lymphocytes were not identified. ACM lesions showed a higher number of CD8+ lymphocytes ( P=0.02) and macrophages ( P=0.01) when compared with EUM lesions. As well as morphologically altered, displaying irregular and short dendritic processes, LC were depleted both in ACM and EUM lesions ( P=0.0004) when compared with normal skin but no difference between both types of mycetoma ( P>0.05) was found. Results suggest that cellular mediated immunity may play a role in mycetoma pathogenesis. The morphological alterations and marked reduction of LC in mycetoma lesions might reflect a depressed cellular immune response, partially explaining the chronic course and unresponsiveness to treatment of this group of diseases.

Madura foot due to Actinomadura madurae: Imaging appearance

We report a rare case of actinomycetoma of the foot (madura foot) due to Actinomadura madurae in a patient living in a Temperate Zone country. Plain radiographs and MRI imaging were useful in establishing the diagnosis.

Therapeutic approaches to subcutaneous mycoses.

Subcutaneous mycoses, which are much less common than superficial fungal infections, are characterized by a heterogeneous group of infections that often result from direct penetration of the fungus into the dermis and subcutaneous tissue through traumatic injury. The fungus spreads by local deep tissue invasion from the inoculation site. The disease usually remains localized and then slowly spreads to adjacent tissue and eventually to the lymphatics. More rarely, hematogenous dissemination is observed. There are usually various clinical features and thus a broad range of differential diagnoses. The common subcutaneous mycoses are sporotrichosis, chromoblastomycosis, phaeohyphomycosis, eumycotic mycetoma, and hyalohyphomycosis. Many subcutaneous mycoses are confined to the tropical and subtropical regions, but some, such as sporotrichosis, are also prevalent in temperate regions. Subcutaneous mycoses can occur in healthy individuals. In immunocompromised individuals, these infections can disseminate widely. Treatment usually involves use of antifungal agents and/or surgical excision. Treatment of some serious subcutaneous mycoses remains unresolved, and there have been reports of relapses or progression during therapy and problems with lack of tolerability of antifungal drugs. Identification of the etiologic agent by culture is essential for prognostic and management considerations, since some fungi are more frequently associated with dissemination. Results of antifungal susceptibility tests may provide valuable information for deciding the appropriate method of treatment. Development of new antifungal agents and combination therapies may result in improvement in the management of subcutaneous mycoses in the future.

Epidemiology, Clinical Manifestations, and Therapy of Infections Caused by Dematiaceous Fungi

The dematiaceous (brown-pigmented) fungi are a large and heterogenous group of moulds that cause a wide range of diseases including phaeohyphomycosis, chro-moblastomycosis, and eumycotic mycetoma. Among the more important human pathogens are Alternaria species, Bipolaris species, Cladophialophora bantiana, Curvularia species, Exophiala species, Fonsecaea pedrosoi, Madurella species, Phialophora species, Scedosporium prolificans, Scytalidium dimidiatum, and Wangiella dermatitidis. These organisms are widespread in the environment, being found in soil, wood, and decomposing plant debris. Cutaneous, subcutaneous, and corneal infections with dematiaceous fungi occur worldwide, but are more common in tropical and subtropical climates. Infection results from traumatic implantation. Most cases occur in immunocompetent individuals. Dematiaceous moulds are also important causes of invasive sinusitis and allergic fungal sinusitis. Infection is thought to follow inhalation. Although cerebral infection is the commonest form of systemic phaeohyphomycosis, other localized deep forms of the disease, such as arthritis, and endocarditis, have been reported. Disseminated infection is uncommon, but its incidence is increasing, particularly among immunocompromised individuals. Scedosporium prolificans is the most frequent cause. A number of dematiaceous fungi are neurotropic, including Cladophialophora bantiana, Ramichloridium mackenziei, and Wangiella dermatitidis. Although cases have occurred in immunocompromised persons, cerebral phaeohyphomycosis is most common in immunocompetent individuals with no obvious risk factors.Most forms of disease caused by dematiaceous fungi require both surgical and medical treatment. Itraconazole is currently the most effective antifungal agent for chromoblastomycosis and subcutaneous phaeohyphomycosis, while ketoconazole remains useful for mycetoma. Extensive surgical debridement combined with amphotericin B treatment is recommended for chronic invasive sinusitis. Long-term treatment with itraconazole has led to improvement or remission in some patients that had failed to respond to amphotericin B. Allergic fungal sinusitis requires surgical removal of impacted mucin combined with postoperative oral corticosteroids. Antifungal treatment is not usually of benefit, but post-operative itraconazole may reduce the need for reoperation. The clinical outcome of cerebral and other deep-seated forms of phaeohyphomycosis is dismal, with long-term survival being reported only when complete surgical resection of discrete lesions is possible. The development of new antifungal agents and combination treatment may help to improve the management of these infections.

Chromoblastomycosis: A review of 100 cases in the state of Rio Grande do Sul, Brazil

Background: If not diagnosed earlier, chromoblastomycosis has a chronic evolutional course that may cause several problems, such as difficulty in managing therapy because of the recrudescent character of the disease, potential association with the growth of epidermoid carcinoma in affected regions, and poor quality of life and work incapacity to the patient. Although infrequent, new cases are reported in the state of Rio Grande do Sul every year, ratifying the necessity for further studies on this disease. Objective: The purpose of this study was to review clinical features and response to therapy in patients with chromoblastomycosis and present data on the demography and history of this disease in the state of Rio Grande do Sul, Brazil. Methods: We reviewed case records of 100 patients with skin lesions caused by chromoblastomycosis, who were treated between 1963 and 1998. The cases were confirmed by the histopathologic and mycologic analyses made by the Dermatology Service of the Universidade Federal do Rio Grande do Sul at the Santa Casa de Misericórdia Hospital. Results: There was a predominance of male patients (4:1) and of white farmers whose ages ranged from 50 to 59 years, with lesions on their lower limbs. Most of them were from the northern regions of the state. The average time between the appearance of the disease and medical diagnosis was 14 years. The verrucous type proved to be the most frequently reported lesion (53%). Thorn wounds were associated with the disease in 16% of the cases. Lesions uncommon to some parts of the body were also reported. In two of the cases, cutaneous lesions caused by paracoccidioidomycosis and chromoblastomycosis were found in the same patient. Epidermoid carcinoma was found in the same parts of the body affected by chromoblastomycosis. Eumycotic mycetoma and chromoblastomycosis were associated. Fonsecaea pedrosoi was found in 96% of the cases, and Phialophora verrucosa in 4% of the cases. Conclusion: In our study, we observed a predominance of cases in the regions of Missões and Alto Uruguay, followed by the upper and lower northeastern slopes and the lowlands. Severe cases of chromoblastomycosis with intense skin involvement (eg, lesions with carcinoma) were observed. Statistical analysis showed recrudescence of the disease in 43% of cases despite the treatment used. (J Am Acad Dermatol 2001;44:585-92.)

Madura foot

Eumycetomas are chronic infectious entities characterized by presence of mycotic grains in (sub-)cutaneous tissues, after accidental inoculation of an exogenous filamentous fungus in the skin. The lesions evolve towards painless pseudotumor of the soft parts. We report the original case of a Guinean woman exhibiting eumycetoma of the right foot. Both laboratory tests identified a dematiaceous fungus, Exophiala jeanselmei, as the responsible infectious agent. A medical treatment with voriconazole alone was sufficient to notice a substantial clinical improvement. This finding is unusual as E. jeanselmei is uncommon in Guinea-Conakry, and as optimal treatment rather associate antifungal azoles and surgical excision.Les eumycétomes constituent des entités infectieuses chroniques caractérisées par la présence de grains fongiques au sein des tissus (sous-)cutanés, après inoculation accidentelle d’un champignon filamenteux exogène. Les lésions évoluent sur un mode indolore vers des pseudo-tumeurs des parties molles. Nous rapportons ici le cas original d’une femme guinéenne avec un eumycétome du pied droit. Les différents examens de laboratoire ont permis d’identifier le champignon dématié Exophiala jeanselmei comme agent responsable. Un traitement médicamenteux par voriconazole seul était suffisant pour visualiser une amélioration clinique sensible. Ce constat est intéressant car E. jeanselmei est une espèce peu commune en Guinée-Conakry et le traitement habituel associe plutôt un antifongique azolé à la chirurgie d’exérèse.

Recurrent mycetoma of the foot

Mycetoma, also known as madura foot, is a local, chronic, slowly progressive disease with the classic presentation involving tumefaction, multiple draining sinuses, and grain-filled pus. It is primarily produced by either a bacteria (actinomycetoma) or a fungal (eumycetoma) organism. Determining the causative organism is fundamental to the treatment process. All types of mycetoma infections should be treated with early surgical debridement and tissue culture. Tissue should be sent for gross, microscopic, and histopathologic evaluation. In addition to surgical management, these patients should be managed adjunctively with a prolonged course of chemotherapy. Patients with actinomycetoma are treated with an antibiotic and can expect to have a clinical cure with little chance for recurrence, whereas, patients with eumycetoma are treated with an antifungal agent and usually do poorly with a high rate of recurrence. The case presented involved an infection due to Actinomadura madurae (Nocardiaform madurae) and demonstrates successful treatment with surgical resection and prolonged doxycycline chemotherapy.

The epidemiologic aspect and the one-week itraconazole therapy of onychomycosis in Zagreb area (Croatia)

Mycetoma, also known as madura foot, is a local, chronic, slowly progressive disease with the classic presentation involving tumefaction, multiple draining sinuses, and grain-filled pus. It is primarily produced by either a bacteria (actinomycetoma) or a fungal (eumycetoma) organism. Determining the causative organism is fundamental to the treatment process. All types of mycetoma infections should be treated with early surgical debridement and tissue culture. Tissue should be sent for gross, microscopic, and histopathologic evaluation. In addition to surgical management, these patients should be managed adjunctively with a prolonged course of chemotherapy. Patients with actinomycetoma are treated with an antibiotic and can expect to have a clinical cure with little chance for recurrence, whereas, patients with eumycetoma are treated with an antifungal agent and usually do poorly with a high rate of recurrence. The case presented involved an infection due to Actinomadura madurae (Nocardiaform madurae) and demonstrates successful treatment with surgical resection and prolonged doxycycline chemotherapy.

P163 Eumycetoma: Treatment remains a problem

P163 Eumycetoma: Treatment remains a problem

Madura foot

Madura foot, or alternatively ‘mycetoma” to include extra pedal manifestations, is a chronic subcutaneous granulomatous infection affecting exposed areas of the body. It is characterized by painless nodules, sinuses and discharge often containing coloured grains. A remarkably similar clinical presentation can be produced by a diverse spectrum of organisms that enter the subcutaneous tissues following often trivial trauma to skin exposed to infected soils, for example, by thorn pricks. The nature of the condition is illustrated by reference to a recent case in our unit and a brief discussion about some important therapeutic points.

Radiological Manifestations of Madura Foot in the Eastern Province of Saudi Arabia

A total of 29 patients with mycologically and histopathologically proven mycetomas were examined for radiological manifestations from April 1984 to March 1996. Twenty cases were actinomycotic mycetomas, while nine were maduromycotic mycetomas. Plain x-rays of the regions of interest were taken in all the cases and CT scan was performed on five selected cases to compare the findings. Soft tissue changes were observed in all the examined cases, while bony changes were observed in 16 (55.7%). CT scan is useful for showing soft tissue changes, erosion and destruction of bone in cases with an early infection only, which cannot be demonstrated in plain radiographs.

Actinomycetoma of the phalanx in an immunocompromised patient: A case report

A case of primary Nocardia asteroides infection of the distal phalanx in an immunocompromised patient is described. Nocardiosis usually manifests itself as pulmonary infection in the immunocompromised host with secondary hematogenous spread to varied organ systems. Primary cutaneous nocardiosis is rare and usually presents as a mycetoma of the foot--Madura foot. A chronic draining infection in the hand--especial ly-in-an immunocompromised patient--that does not respond to usual surgical drainage and conventional antibiotics should raise the suspicion of atypical infection from a mycobacterial, fungal, or actinomycete source.

Mycetoma of the foot ? surgical treatment with free flap reconstruction

Mycetoma (Madura foot) is a chronic fungal or bacterial infectious process characterized by a discharging mass. Medical treatment is generally insufficient, and surgical eradication, sometimes by amputation, is advocated. Although a benign disease, the tumor's nature may be considered malignant in view of limb's fate. Reconstruction of a foot with a free tensor fascia lata musculocutaneous flap, following large mycetoma mass resection in a 28-year-old patient is described. A year after surgery, the patient uses the leg without limitation and no recurrence is evident. This limb preservation technique, which enables rapid rehabilitation and ambulation, is superior to amputation.

“Madura foot” caused by actinomadura madurae

“Madura foot” caused by actinomadura madurae

Unusual pathological condition in the lower extremities of a skeleton from ancient Israel

We report here an unusual pathology in a 1,500-year-old skeleton recovered from Bet Guvrin, Israel. The pathological changes in the lower extremities and the diagnostic difficulties are presented. We attribute this condition to Madura foot, found primarily in tropical and subtropical regions, although other diagnoses are possible and are noted. We discuss its appearance in the region in light of the historical context.

Neotestudina rosatii . [Descriptions of Fungi and Bacteria

Abstract A description is provided for Neotestudina rosatii . Information is included on the disease caused by the organism, its transmission, geographical distribution, and hosts. HOSTS: Isolated from white-grained mycetomas in man, also from Arachis, Coriandrum, Delonix, Juglans, Lycopersicon, Sorghum, Vigna and soil. DISEASE: White-grained mycetoma in man (madura foot infection). GEOGRAPHICAL DISTRIBUTION: Africa (Cameroun, Chad, Congo, Guinea, Nigeria, Senegal, Somalia, Sudan), Australia, India. TRANSMISSION: Presumably by airborne dispersal of ascospores.

Madura foot: a surgical cure.

Madura foot: a surgical cure.

Mycetoma of the foot caused by Cylindrocarpon destructans

A 39-year-old male, originally from Antigua, West Indies, presented with a 12-year history of swelling of the left foot. A pathogen could not be recovered in cultures of three surgical biopsy specimens. During follow-up, pus and grains were expressed from a draining sinus tract and Cylindrocarpon destructans grew in pure culture. Retrospective examination of histologic sections of tissue removed during the third biopsy demonstrated a grain characteristic of eumycotic mycetoma. Although the fungus was susceptible to amphotericin B and ketoconazole in vitro, the patient refused treatment, and the clinical course over almost 19 years has been one of slow but progressive bone destruction. The fungus was identified by its microconidial morphology, the presence of chlamydospores, and an intense brown diffusible pigment. It was compared with another poorly known agent of white grain mycetoma, Phialophora cyanescens, characterized by phialidic conidia, chlamydospores in aggregations, and an intense diffusing pigment. The new combination Cylindrocarpon cyanescens (de Vries et al.) Sigler comb. nov. is proposed.