Fungal Mycetoma Research Articles

Imaging approach for fungal sinusitis.

This article provides a comprehensive review of the computed tomography (CT) and magnetic resonance (MR) imaging findings of invasive fungal sinusitis with an emphasis on pattern recognition and approach to interpretation. Fungal sinusitis is categorized into invasive (acute, chronic, and granulomatous) and noninvasive forms (allergic fungal sinusitis and mycetoma). CT is superior for detecting bony erosion and hyperdense fungal elements, while MRI excels in evaluating soft tissue and mucosal involvement. Key radiologic signs such as bone destruction, sinus wall thickening, and 'black turbinate sign' aid in early diagnosis, especially in invasive cases. Early imaging signs can be subtle. Early detection is necessary, particularly in immunocompromised patients with acute invasive fungal sinusitis, where rapid intervention is critical. Pattern recognition and adequate interpretation of fungal sinusitis are possible using CT and MRI. Imaging can also help identify complications, aiding with reliable diagnosis and prompt intervention.

Environmental detection of eumycetoma pathogens using multiplex real-time PCR for soil DNA in Sennar State, Sudan

BackgroundMycetoma is a chronic disease affecting the skin and subcutaneous tissue endemic in the tropical and subtropical regions. Several bacteria and fungi can cause mycetoma, but fungal mycetoma (eumycetoma) is challenging because the treatment requires a combination of a long-term antifungal agent and surgery. Although the transmission route has not yet been elucidated, infection from the soil is a leading hypothesis. However, there are few soil investigation studies, and the geographical distribution of mycetoma pathogens is not well documented. Here, we used multiplex real-time PCR technology to identify three fungal species from soil samples.MethodsIn total, 64 DNA samples were extracted from soil collected in seven villages in an endemic area in Sennar State, Sudan, in 2019. Primers and fluorescent probes specifically targeting the ribosomal DNA of Madurella mycetomatis, Falciformispora senegalensis, and F. tompkinsii were designed.ResultsMultiplex real-time PCR was performed and identified the major pathogen, M. mycetomatis that existed in most sites (95%). In addition, two other pathogens were identified from some sites. This is the first report on the use of this technique for identifying the eumycetoma causative microorganisms.ConclusionsThis study demonstrated that soil DNA investigation can elucidate the risk area of mycetoma-causative agents. The results will contribute to the design of prevention measures, and further large-scale studies may be effective in understanding the natural habitats of mycetoma pathogens.

Effect of Mycetoma in Lung Transplant Patients – a Single Center Experience

Mycetomas are uncommon in lung transplant recipients. Prior studies have shown increased mortality associated with mycetoma in lung transplant recipients (LTR). We reviewed our center's experience in outcome of LTRs with pre -or post-transplant mycetoma. We retrospectively reviewed electronic health records of LTRs performed at our institute between January 1, 2013 to December 31, 2020. Mycetoma was present in less than 1 percent of LTR patients (7/1086). Mean age at the time of the transplant was 65 years. Idiopathic pulmonary fibrosis (5/7), interstitial lung disease (1/7), and sarcoidosis (1/7) were underlying pulmonary diagnoses. Seventy-one percent (5/7) received single lung transplant and 29% received double lung transplant. Seventy-one percent had negative serum galactomannan vs 29% (2/7) of patients who had positive serum galactomannan (one post and one pre). Fifty-seven percent had positive bronchoalveolar aspergillus galactomannan (23% had negative). A total of 42% (3/7) were found to have mycetoma before transplant and 58% (4/7) had mycetoma post transplant. Chest computed tomography findings in all patients were consistent with mycetoma. In our cohort of patients, mycetoma was not found to be the primary cause of death if diagnosed pre transplant. Transplant recipients with mycetoma pre transplant did not develop invasive fungal infection or mycetoma post transplant. Careful evaluation of lung transplant candidates with mycetoma is critical. Further studies are needed to determine optimal duration of antifungal therapy and to determine if surgical resection may be needed to manage post-lung transplant mycetoma.

Comparing the performance of the common used eumycetoma diagnostic tests.

Mycetoma is a neglected tropical implantation disease caused by 70 different infectious agents. Identifying the causative organism to the species level is essential for appropriate patient management. Ultrasound, histopathology, culture and two species-specific PCRs are most the commonly used methods for species identification in endemic regions. The aim of this study was to compare the diagnostic performance of these commonly used assays using sequencing of barcoding genes as the gold standard. This descriptive cross-sectional study was conducted at the Mycetoma Research Centre, University of Khartoum, Sudan. It included 222 patients suspected of fungal mycetoma caused by Madurella mycetomatis. 154 (69.3%) were correctly identified by ultrasound, histology, culture and both species-specific PCRs. In 60 patients, at least one of the diagnostic tests failed to identify M. mycetomatis. Five patients had no evidence of eumycetoma, and for three, only the ultrasound was indicative of mycetoma. The two species-specific PCRs were the most sensitive and specific methods, followed by culture and histology. Ultrasound was the least specific as it only allowed differentiation between actinomycetoma and eumycetoma. The time to result was 9.38 minutes for ultrasound, 3.76 hours for PCR, 8.5 days for histopathology and 21 days for grain culturing. Currently, PCR directly on DNA isolated from grains is the most rapid and reliable diagnostic tool to identify M. mycetomatis eumycetoma.

Radiological Evaluation of Cases of Fungal Mycetoma in the Maxillary Sinus

副鼻腔真菌症は病態により急性浸潤性，慢性浸潤性，慢性非浸潤性，アレルギー性の4つに分類され，このうち慢性非浸潤性が最も頻度が高い。これは通常一側性で上顎洞に多く，しばしば保存加療抵抗性で，病変除去のみならず浸潤性真菌症への移行を防ぐ目的で内視鏡下手術が行われる。

S4.5d Comparing the diagnostic performance of the commonly used eumycetoma diagnostic tests using sequencing of the internally transcribed spacer region as the gold standard

S4.5 Mycetoma Clinical Trial on fosravuconazole treatment in eumycetoma– Top Line Results, September 22, 2022, 10:30 AM - 12:00 PM ObjectivesMycetoma is a neglected tropical implantation disease caused by 70 different infectious agents. Identifying the causative organism to the species level is essential for appropriate patient management. Ultrasound, histopathology, culture, and two species-specific PCRs are most the commonly used methods for species identification in endemic regions. The aim of this study was to compare the diagnostic performance of these commonly used assays using sequencing of barcoding genes as the gold standard.MethodsThis descriptive cross-sectional study was conducted at the Mycetoma Research Centre, University of Khartoum, Sudan. It included 222 patients suspected of fungal mycetoma caused by Madurella mycetomatis.ResultsIn total 154 (69.3%) were correctly identified by ultrasound, histology, culture, and both species-specific PCRs. In 60 patients, at least one of the diagnostic tests failed to identify M. mycetomatis. A total of five patients had no evidence of eumycetoma, and for three, only the ultrasound was indicative of mycetoma. The two species-specific PCRs were the most sensitive and specific methods, followed by culture and histology. Ultrasound was the least specific as it only allowed differentiation between actinomycetoma and eumycetoma. The time to result was 9.38 minutes for ultrasound, 3.76 h for PCR, 8.5 days for histopathology, and 21 days for grain culturing.ConclusionCurrently, PCR directly on DNA isolated from grains is the most rapid and reliable diagnostic tool to identify M. mycetomatis eumycetoma.

P445 Clinical evaluation of the performance of the most commonly used eumycetoma diagnostic tests using sequencing of the internally transcribed spacer region as the golden standard

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMObjective: Mycetoma is a neglected tropical skin disease, caused by 70 different causative agents. For most of the causative agents, molecular identification is the only reliable method to identify the species level. In practice, ultrasound, histopathology, culturing, and species-specific PCRs are most commonly used for species identification. However, the performance of these different tests was not validated using molecular identification by sequencing barcoding genes.MethodsIn this study, we validated the performance of the most commonly used diagnostic tools including culture, histopathology, Ultrasound and two species-specific PCR for Madurella mycetomatis on 222 patients suspected of fungal mycetoma by M. mycetomatis; the sensitivity, specificity, and accuracy of each method was calculated.ResultsFrom the 222 patients, 154 (69.3%) were correctly identified by ultrasound, histology, culture, and both species-specific PCRs. For five patients all tests were negative and for three only the ultrasound was indicative of mycetoma. For the other 60 patients, at least one of the assays was negative for M. mycetomatis. The two species-specific PCRs were the most sensitive and specific, followed by culture and histology. Ultrasound was the least specific as it only allows to differentiate between actinomycetoma and eumycetoma. However, with ultrasound, an identification could be obtained in 9.38 min. PCR took 3.76 h, histology 8.5 days, and culturing 21 days.ConclusionWe concluded that PCR directly on DNA isolated from grains is the most rapid and reliable diagnostic tool to identify M. mycetomatis from eumycetoma grains to use species-specific PCRs. In order to shorten the time to identification of other causative agents, the focus should be on developing more molecular assays for those species.

Atypical presence of Pseudallescheria boydii in a soft tissue infection in a patient from Southwest India

Pseudallescheria boydii is ubiquitous in nature and one of the most common causes of fungal mycetoma in temperate regions. Traumatic implantation of P. boydii into subcutaneous tissue or aspiration of contaminated water is some of the methods that can result in human infection (Hay, 1993). This fungus is infamous for its refractoriness toward therapy, predominantly seen in patients who are immunocompromised and resistance to several antifungal agents (Guarro et al., 2006; Tammer et al., 2011). We report an atypical case of P.

Detection of multiple mycetoma pathogens using fungal metabarcoding analysis of soil DNA in an endemic area of Sudan

Mycetoma is a tropical disease caused by several fungi and bacteria present in the soil. Fungal mycetoma and eumycetoma are especially challenging to treat; therefore, prevention, early diagnosis, and early treatment are important, but it is also necessary to understand the geographic distribution of these pathogenic fungi. In this study, we used DNA metabarcoding methodology to identify fungal species from soil samples. Soil sampling was implemented at seven villages in an endemic area of Sennar State in Sudan in 2019, and ten sampling sites were selected in each village according to land-use conditions. In total, 70 soil samples were collected from ground surfaces, and DNA in the soil was extracted with a combined method of alkaline DNA extraction and a commercial soil DNA extraction kit. The region for universal primers was selected to be the ribosomal internal transcribed spacer one region for metabarcoding. After the second PCR for DNA library preparation, the amplicon-based DNA analysis was performed using next-generation sequencing with two sets of universal primers. A total of twelve mycetoma-causative fungal species were identified, including the prime agent, Madurella mycetomatis, and additional pathogens, Falciformispora senegalensis and Falciformispora tompkinsii, in 53 soil samples. This study demonstrated that soil DNA metabarcoding can elucidate the presence of multiple mycetoma-causative fungi, which may contribute to accurate diagnosis for patient treatment and geographical mapping.

Subcutaneous Mycosis in Hospitals: Study of 3 Cases at The National University Hospital Centre Hubert Koutoukou Maga in Cotonou (Benin)

Introduction: Deep subcutaneous mycosis results from the involvement of subcutaneous tissue by microscopic fungi. Few studies have been conducted on these diseases in Benin. Patients and methods: This was a retrospective descriptive study that included all cases of subcutaneous mycosis recorded in the Dermatology-Venerology Department of the CNHU-HKM from 2009 to 2020. Results: 3 cases of deep subcutaneous mycosis were recorded in 12 years, including two cases of basidiobolomycosis and one case of fungal mycetoma. The cases of basidiobolomycosis were observed in two girls aged 7 and 8 years whose lesions were located on the right buttock, in the form of indurated placards, adherent to the superficial plane, measuring respectively 10cm by 5cm and 14cm by 7cm. Mycological examination of the biopsy specimens isolated Basidiobolus ranarum. The only case of fungal mycetoma was observed in a 39-year-old man, in the form of a nodular placard measuring 14cm by 12cm, polyfistulised, inflammatory and squamous-crusty with an irregular border that had been evolving for 15 years. Mycological examination of the pus revealed the presence of black grains and the identification of Madurella mycetomatis. Treatment with Ketoconazole was initiated in all three patients but the evolution could not be appreciated. Conclusion : Subcutaneous mycosis is rare in Cotonou, but probably underestimated. Keywords: Subcutaneous Mycosis; Mycetoma; Basidiobolomycosis; Benin

Modelling the spatial distribution of mycetoma in Sudan.

BackgroundMycetoma is a neglected tropical disease that is reported worldwide and Sudan has the highest reported number of mycetoma infections across the globe. The incidence, prevalence and burden of mycetoma globally are not precisely known and its risk factors remain largely unelucidated.MethodsThis study aimed to identify the environmental predictors of fungal and bacterial mycetoma in Sudan and to identify areas of the country where these niche predictors are met. Demographic and clinical data from confirmed mycetoma patients seen at the Mycetoma Research Centre from 1991 to 2018 were included in this study. Regression and machine learning techniques were used to model the relationships between mycetoma occurrence in Sudan and environmental predictors.ResultsThe strongest predictors of mycetoma occurrence were aridity, proximity to water, low soil calcium and sodium concentrations and the distribution of various species of thorny trees. The models predicted the occurrence of eumycetoma and actinomycetoma in the central and southeastern states of Sudan and along the Nile river valley and its tributaries.ConclusionOur results showed that the risk of mycetoma in Sudan varies geographically and is linked to identifiable environmental risk factors. Suitability maps are intended to guide health authorities, academic institutes and organisations involved in planning national scale surveys for early case detection and management, leading to better patient treatment, prevention and control of mycetoma.

1161. Effectiveness of Posaconazole in the Treatment of Rare Invasive Fungal Infections: A Systematic Literature Review

BackgroundRare invasive fungal infections (IFIs) such as chromoblastomycosis (CBM), fungal mycetoma (mycetoma), hyalohyphomycosis/phaeohyphomycosis (hyalo/phaeo), and mucormycosis (mucor) cause significant morbidity and mortality in immunocompromised patients. Few effective treatment options are available for these IFIs, therefore we assessed the clinical efficacy of posaconazole, a broad-spectrum triazole antifungal compound with demonstrated activity against IFIs.MethodsWe performed a systemic literature review of Medline and EMBASE to identify studies published from 2005 (year of posaconazole approval) to October 30, 2019, reporting the efficacy/effectiveness of posaconazole monotherapy or combination therapy for treating CBM, mycetoma, hyalo/phaeo, and mucor. Two reviewers screened and extracted data based on predefined PICOS criteria. Effectiveness outcomes included cure, response, relapse, radiologic improvement; mortality and any other effectiveness measures reported. Study quality was assessed using National Institute for Health and Care Excellence-recommended checklists. A narrative descriptive summary was used to summarize study findings.ResultsOf 2612 articles identified, 351 articles (mostly case reports) were included. Positive clinical outcomes with posaconazole therapy were observed in most patients with CBM (73.9%, 17/23), mycetoma (100%, 2/2), hyalo/phaeo (53.3%, 49/92), and mucor (66.7%, 564/845). The population for mycetoma was small; only 2 positive cases (Figure). Overall survival was ~70% or greater across the IFIs examined. Posaconazole efficacy and mortality differed by line of therapy as well as for monotherapy versus combination therapy. Positive response was higher in second line monotherapy than first line monotherapy in CBM and mucor. Higher mortality was observed with combination therapy than monotherapy in hyalo/phaeo and mucor infections (except for first line use in mucor).Figure. Overall Results of Posaconazole Treatment ConclusionDespite the rarity of these IFIs, substantial data have been published since posaconazole’s initial approval in the year 2005, and the evidence demonstrates that posaconazole is an effective therapeutic option alone or in combination for the treatment of these rare IFIs.DisclosuresMark Bernauer, BPharm, RPh, Merck & Co, Inc. (Consultant) Hetty Waskin, MD/MPH, Merck & Co, Inc. (Employee) Nicole Cossrow, PhD, Merck & Co, Inc. (Employee) Allysen Kaminski, BA, Merck & Co, Inc. (Consultant) Havilland Campbell, BS, Merck & Co, Inc. (Employee) Dipen Patel, BPharm, PhD, Merck & Co, Inc. (Consultant)

FUNCTIONAL ENDOSCOPIC SINUS SURGERY

Treatment of sinonasal diseases is either conservative or surgical. The recent advances in surgical management is the use of endoscopic sinus surgery (ESS) as it causes less morbidity, complication, pain and above all, less recurrence rates. This study aimed to evaluate the effectiveness of ESS for the treatment of nasal & paranasal sinus diseases and to address the postoperative complications. A prospective study was done at the Department of Otolaryngology in Basrah Teaching Hospital in the period from January 2016 to August 2019. One hundred twenty six patients with sinonasal diseases were involved in this study, more than this number of patients was operated upon but they either refused participation in this study or dropped from follow-up. The main indications of surgery were; chronic rhinosinusitis without nasal polyp (33%), chronic rhinosinusitis with nasal polyp (28.6%), Allergic fungal sinusitis & mycetoma (17.4%), and acute recurrent sinusitis (16%). Main presenting symptoms were; nasal obstruction (85.7%), nasal discharge (69%), headache and facial pain (66.6%) and hyposmia and or anosmia (57.9%). The majority of operated upon patients were primary cases (98 patients, 77.7%), while (28 patients, 22.2%) were revision cases. The commonest causes of revision were; retained or incompletely removed uncinate process in 28.5% of cases, followed by incomplete removal or persistence of anterior ethmoid cells in 21.4% cases. In this series complications occurred in 15%, which were generally minor (9.5%), major complications occurred in 5.5% of operated upon patients. The commonest major complication is sever bleeding which was reported in 4.7% and anosmia which was reported in one patient. No CSF leak, retro orbital haemorrhage, or blindness was reported. Most of the patients in this series were improved (88.8%), complete symptom improvement occurred in (75 patients, 59.5%), partial improvement (37 patients, 29.3%), while (14 patients, 11%) were not improved. In conclusion, functional endoscopic sinus surgery is a safe surgery for sinonasal diseases, it carry good success rate with non-significant major complications. Key words: Nasal Sinus, Functional Surgery, Endoscopy

Mycetomas in the Endemic Area of Argentina

To describe the different characteristics of mycetoma in the endemic area of Argentina and its etiological agents, using mainly data from Santiago del Estero and Salta provinces. Argentina is not considered an important endemic area, but it possesses a large documented casuistry and many non-published cases of patients. Santiago del Estero presents the greatest quantity of mycetoma cases of the country, mainly by Actinomadura madurae. The First Argentinian Mycetoma Reunion took place in 2016, which was the starting point to train medics and healthcare professionals of the province, which are the first to enter into contact with the patient. The described endemic area has very diverse climatic and ecologic characteristics. This has direct impact in the causal agents of mycetoma. Actinomycotic mycetomas by Nocardia spp. abounds in the zones with greater rain regime and sugar cane cultivation, while in arid or semi-arid zones with low rain regime, A. madurae and fungal mycetomas predominate.

Fungal ball of the maxillary sinus and the risk of persistent sinus dysfunction after simple antrostomy

Maxillary sinus fungal ball is a common cause of unilateral maxillary sinusitis. Fungal balls or mycetomas are primarily treated with surgery to remove the fungus. However, this assumes the pre-fungal ball sinus cavity was normal and post-surgery patients may suffer from mucostasis in the sinus cavity with persistent symptoms. It is proposed that fungal balls are potentially a feature of impaired mucus clearance as they are a pathology in their own right. A case series of consecutive patients undergoing antrostomy for maxillary sinus fungal ball was performed. Patient factors including age, gender, smoking status, comorbidities (allergy, asthma, and reflux), disease specific factors including duration of symptoms, microbiology (bacterial co-infection, Gram-positive and/or Gram-negative) and preoperative radiologic findings (extent of sinus development, and neo-osteogenesis/bone thickness) were collected. The primary outcome was sinus function defined by evidence of a normal functioning maxillary sinus, with the absence of mucostasis or pooling, on endoscopic exam at three months, six months and last follow-up. Endoscopic evaluation of inflammation was also collected. 28 patients (age 58.5±15.5years, 64.3% female) were assessed. Mucostasis was present at three months in 39.3%, at six months in 32.1%, and 17.9% at last follow-up. There was no comorbidity or radiologic finding that was associated with failure to normalize. Those patients with mucostasis had a higher modified Lund-Mackay endoscopic score at last follow-up (5.0±0.7 v 0.2±0.6, p<0.01). Long term post-operative mucostasis occurred in 17.9% of patients following an adequate maxillary antrostomy for treatment of a fungal ball. Patients with mucostasis had persistent mucosal inflammation and a greater need for further surgery (modified medial maxillectomy).

Clinical study of fungal sinusitis

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Fungal sinusitis is a distinct clinical entity characterized by inflammation of the sinus mucosa caused by fungal infection like aspergillus (fumigatus, niger, flavus), mucormycosis, candida (albicans), scedosporium, pencillium. Mostly immunocompromised patients, farmers, garbage cleaners, and patients on prolonged nasal sprays are affected. There are different types of fungal sinusitis: fungal mycetoma, allergic fungal, chronic indolent and fulminant sinusitis having symptoms like chronic headache and facial swelling with visual impairment. Patients have thick purulent nasal discharge, nasal obstruction, epistaxis, cheek swelling and may be polyposis. Resident bacterial flora probably inhibits colonization by fungi through a number of mechanisms. Thus antimicrobial therapy predisposes to both the overgrowth of normal fungal flora, e.g., Candida species, and growth of opportunists like Aspergillus&lt;sup&gt;1&lt;/sup&gt;. Allergic fungal rhinosinusitis is the most common entity. Aspergillosis is the most common fungal infection. Of these aspergillus fumigatus is the most common fungal pathogen. Maxillary sinuses are commonly involved.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a prospective study carried out at department of otorhinolaryngology at Kunal Institute of Medical Specialities Pvt Ltd. Evaluation by proper history taking and clinical examination after which the patient is selected for nasal swab, culture and sensitivity. Plain x-ray nose and paranasal sinuses. CT scans nose and paranasal sinuses. Diagnostic nasal endoscopy. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Allergic fungal sinusitis was the most common entity found with aspergillosis being the most common organism.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Allergic fungal sinusitis was most commonly found in the age group of 20 to 29 years with maxillary sinus most commonly affected. &lt;/p&gt;

Current Treatment of Mycetoma

The purpose of this review is to update the status of treatment of actinomycetoma and eumycetoma. Specific information is presented to describe the best medical management for uncomplicated and complicated actinomycetic and fungal mycetomas. Localized actinomycetoma that involves the skin without affecting underlying organs is treated with trimethoprim/sulfamethoxazole for 3 to 12 months. In extensive infections with bone or deep organ involvement and in those with no therapeutic response, amikacin can be added. Duration of treatment varies from 5 to 20 weeks and will depend on clinical response, development of adverse effects, and patient comorbidities. Other antibiotics including diaminodiphenylsulfone (DDS), amoxicillin/clavulanic acid, rifampicin, minocycline, moxifloxacin, imipenem, meropenem, and linezolid may be employed in different combinations in selected cases. If available, an antibiogram should guide antimicrobial therapy. Eumycetoma treatment includes itraconazole, voriconazole, posaconazole, and terbinafine. Surgery is indicated depending on disease extension, antifungal clinical response, and localization. Trimethoprim/sulfamethoxazole (TMP/SMZ) is the drug of choice for actynomicetoma but amikacin can be added in complicated cases. When aminoglycosides are contraindicated, other antimicrobials can be employed; surgery is seldom indicated. In eumycetoma, itraconazole is currently the first-line therapy, and terbinafine can be added in complicated cases. Other azoles are unavailable or expensive. Experimental in vitro and in vivo studies with different antimicrobials are currently underway for actinomycetoma. In eumycetoma, a comparative double-blind randomized study with itraconazole and fosravuconazole along with surgical treatment is being carried out at the Mycetoma Research Center in Khartoum, Sudan. Clinical awareness about mycetoma among physicians will allow a prompt diagnosis and treatment.

Mycetoma in the Togolese: An Update from a Single-Center Experience

BackgroundMycetoma is a chronic inflammatory process caused either by fungi (eumycetoma) or bacteria (actinomycetoma). In this retrospective study, we report epidemiologic and histopathological data of mycetoma observed in the Lome Hospital, Togo in a 25-year period (1992–2016).MethodologyThis is a retrospective study, over a period of 25 years, to analyze epidemiological and etiological findings of mycetomas seen in the single laboratory of pathological anatomy of the Lomé, Togo.ResultsA total of 61 cases were retrieved from which only 33 cases were included which where clinically and microbiologically confirmed. The mean age of the patients was 29.7 ± 1.34 and a sex ratio (M/F) of 1.5. The majority of patients were farmers (n = 23 cases; 69.7%). Diagnosed etiologic agents were fungal in 24 cases (72.7%) and actinomycotic cases in 9 cases (27.3%). The fungal mycetomas consisted of Madurella mycetomatis (black grains) and Falcifomispora senegaliensis (black grains). The actinomycotic agents were represented by Actinomadura madurae (white grains), Actinomadurae pelletieri (red grains) and Nocardia sp. (yellow grains).ConclusionThis report represents a single-center study which provides epidemiologic and histopathological data of mycetoma cases in Togo.

Identification by Molecular Methods and Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry and Antifungal Susceptibility Profiles of Clinically Significant Rare Aspergillus Species in a Referral Chest Hospital in Delhi, India.

Aspergillus species cause a wide spectrum of clinical infections. Although Aspergillus fumigatus and Aspergillus flavus remain the most commonly isolated species in aspergillosis, in the last decade, rare and cryptic Aspergillus species have emerged in diverse clinical settings. The present study analyzed the distribution and in vitro antifungal susceptibility profiles of rare Aspergillus species in clinical samples from patients with suspected aspergillosis in 8 medical centers in India. Further, a matrix-assisted laser desorption ionization-time of flight mass spectrometry in-house database was developed to identify these clinically relevant Aspergillus species. β-Tubulin and calmodulin gene sequencing identified 45 rare Aspergillus isolates to the species level, except for a solitary isolate. They included 23 less common Aspergillus species belonging to 12 sections, mainly in Circumdati, Nidulantes, Flavi, Terrei, Versicolores, Aspergillus, and Nigri Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) identified only 8 (38%) of the 23 rare Aspergillus isolates to the species level. Following the creation of an in-house database with the remaining 14 species not available in the Bruker database, the MALDI-TOF MS identification rate increased to 95%. Overall, high MICs of ≥2 μg/ml were noted for amphotericin B in 29% of the rare Aspergillus species, followed by voriconazole in 20% and isavuconazole in 7%, whereas MICs of >0.5 μg/ml for posaconazole were observed in 15% of the isolates. Regarding the clinical diagnoses in 45 patients with positive rare Aspergillus species cultures, 19 (42%) were regarded to represent colonization. In the remaining 26 patients, rare Aspergillus species were the etiologic agent of invasive, chronic, and allergic bronchopulmonary aspergillosis, allergic fungal rhinosinusitis, keratitis, and mycetoma.

Role of a NSAID in the apparent cure of a fungal mycetoma

We report the case of a fungal mycetoma due to Madurella mycetomatis that failed to respond to surgery and antifungal treatment but responded strongly to the addition of a non-steroidal anti-inflammatory drug (NSAID). This African patient was born in Mauritania in 1972. He was a herdsman, living close to the Senegal River. The first nodules appeared on the left foot at the age of 13years (1985). The patient suffered frequent flare-ups with the appearance of black grains and underwent surgery in 1988 and 1992 in Senegal. After remission for several months after surgery, new fistulae occurred. The patient emigrated to France in 1995 and underwent a third surgical intervention in 1996. M.mycetomatis was cultured from the black grains. The patient was otherwise in good health, with no diabetes, and HIV tests were negative. We saw the patient for the first time in 2005, at which time he had flare-ups every two to three months. Imaging disclosed an absence of bone involvement. The patient underwent a fourth operation in October, 2005, and voriconazole treatment was initiated. A new flare-up occurred in February, 2006. CT, MRI, and PET scans revealed calcaneus and tarsal involvement, and posaconazole then replaced voriconazole. Flucytosine was added four months later, due to an absence of improvement. New flares-ups occurred and a fifth surgical intervention was performed in September, 2006. The pain, which had been present for three years, worsened; the patient had to stop working and was no longer able to walk without crutches. Amputation of the foot was considered. Empiric treatment with a NSAID, diclofenac (Voltaren(®); 100mg/day), was added to the antifungal treatment in November 2006, to treat the patient's pain and inflammation. A major improvement was observed within one week. The patient was able to walk without crutches one month later. After two months, clinical examination was normal: no pain, inflammation, nodules or fistulae. Flucytosine was stopped after six months of treatment, in January 2007, diclofenac after 10months, in October 2007, and posaconazole after 18.5months, also in October 2007. No relapse has occurred during the eight years of follow-up since treatment ended. The patient seems to have been cured and has normal CT, MRI, and PET scans. This eumycetoma, which had progressed over 20years despite surgery and antifungal treatments, seems to have been cured by the addition of a NSAID. This observation suggests that inflammation plays a major role in the pathogenesis of fungal mycetoma. Clinical studies of treatments including an NSAID should be conducted to confirm this finding.