MYCETOMA

Dr.T.V.Rao MD

Dr.T.V.Rao MD

What is Mycetoma
Mycetoma is a chronic granulomatous, progressive inflammatory disease that involves the subcutaneous tissue after a traumatic inoculation of the causative organism. It may be caused by true fungi (eumycetes) or by higher bacteria (actinomycetes) and therefore it is classified into eumycetoma and actinomycetoma respectively.
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Mycetoma
Mycetoma is a chronic subcutaneous infection caused by actinomycetes or fungi. This infection results in a granulomatous inflammatory response in the deep dermis and subcutaneous tissue, which can extend to the underlying bone.
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Mycetoma
Mycetoma is characterized by the formation of grains containing aggregates of the causative organisms that may be discharged onto the skin surface through multiple sinuses. Mycetoma was first described in the mid 1800s and initially named Madura foot, after the region of Madura in India where the disease was first identified.
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Mycetoma
Mycetoma caused by Microaerophilic actinomycetes is termed actinomycetoma, and mycetoma caused by true fungi is called eumycetoma.
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Presentation of Mycetoma
The characteristic triad of a painless subcutaneous mass, sinuses and the discharge of grains is pathognomic of mycetoma. The lesion usually presents as a slowly progressive painless swelling at the site of previous trauma and gradually increases in size. It may spread to involve the skin and deep structures resulting in destruction of bone, deformity and loss of function with serious social and economic implications.
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Madura foot
Madura foot is a chronic granulomatous infection of the bones and soft tissues of the foot resulting in mycetoma formation and gross deformity. It occurs in Sudan, North Africa and the west coast of India, principally among those who walk barefoot and are therefore prone to contamination of foot injuries by soil-derived organisms.
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Madura foot
A common causative organism is Actinomadura madurae, but Madura foot is also caused by other actinomycetes including Streptomyces somaliensis and by fungi

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Aetiological Agents of Mycetoma

More than 20 species of fungi and bacteria can cause mycetoma. The ratio of mycetoma cases caused by bacteria (actinomycetoma) to those caused by true fungi (eumycetoma)
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Actinomadura spp

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Mycetoma
The body parts affected most commonly in persons with mycetoma include the foot or lower leg, with infection of the dorsal aspect of the forefoot being typical. The hand is the next most common location; however, mycetoma lesions can occur anywhere on the body.
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Mycetoma Lesions
Lesions on the chest and back are frequently caused by Nocardia species, whereas lesions on the head and neck are usually caused by Streptomyces somaliensis.
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Pathogenesis
The causative organism enters through sites of local trauma (eg, cut on the hand, foot splinter, local trauma related to carrying soilcontaminated material). A neutrophilic response initially occurs, which may be followed by a granulomatous reaction. Spread occurs through skin facial planes and can involve the bone. Haematogenous or lymphatic spread is uncommon.
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Actinomycetoma can be caused by the following:

Actinomadura

madurae Actinomadura pelletieri Streptomyces somaliensis Nocardia species

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Clinical Presentations of Mycetoma

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Clinical Presentations of Mycetoma

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Eumycetoma
Eumycetoma is mainly caused by P boydii (S apiospermum) or Madurella mycetomatis.
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Botryomycosis
Botryomycosis is a chronic, Suppurative infection characterized by a granulomatous inflammatory response to bacterial pathogens; it may present with cutaneous or, less commonly, visceral involvement . The term botryomycosis is derived from the Greek word botrys (meaning "bunch of grapes") and mycosis (a misnomer, due to the presumed fungal etiology in early descriptions).
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Botryomycosis
Other terms used to describe botryomycosis include bacterial pseudomycosis, staphylococcal actinophytosis, granular bacteriosis, and actinobacillosis
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Fine needle Aspiration Cytology of Mycetoma:

Mycetoma can be accurately diagnosed by Fine Needle Aspiration (FNA) cytology. Mycetoma lesion has a distinct appearance in a cytology smear characterised by the presence of polymorphous inflammatory cells consisting of an admixture of neutrophils, lymphocytes, plasma cells,

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Identification of pathogens
The mycetoma causative organisms can be identified by their textural description, morphological and biological activities in pure culture. The biological activity may include acid fastness, optimal temperature, proteolytic activity, utilization of sugars and nitrogenous compounds. The grains are the source of the culture and they should be alive and free of contaminants and they are usually obtained by deep surgical biopsy.
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Treatment of Mycetoma
The treatment of mycetoma depends mainly on its aetiological agent and the extent of the disease. Until recently, in many centres, the only available treatment for mycetoma was amputation or mutilating surgical excision of the affected part
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Treatment of Mycetoma
Actinomycetoma is amenable to medical treatment with antibiotics and other chemotherapeutic agents. Combined drug therapy is always preferred to a single drug to avoid drug resistance and to eradicate residual infection. The common drugs regimes are: 1- Amikacin sulphate (15 mg/kg) in combination with Co-trimoxazole(14 mg/kg twice daily) is the first line for actinomycetoma treatment.
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Surgical Treatment
Surgical excision is recommended for small localized lesions, debulking of massive lesions; for better response to medical treatment and for lesions became well encapsulated by medical treatment. Amputation rarely done nowadays. It is done for very advanced lesions with bad general condition and as a life saving procedure.
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