Causes:

MYCETOMA is an infection with fungi (eumycetoma) or bacteria (actinomycetoma)

Mycetoma caused by more than 56 different bacteria and fungi.

Organisms are found in soil & transmitted through a thorn prick to foot or similar trauma.

Most common eumycetoma causes- Madurella mycetomatis, Madurella grisea, Pseudoallescheria boydii, and Leptosphaeria senegalensis.

Most common actinomycetoma causes- Nocardia spp., Actinomadura spp., and Streptomyces somaliensis.

Mycetoma is most common in men, aged 20-40 years, poors, rural areas, farmers, & field laborers.

Symptoms:

characteristic triad consisting of painless, firm, subcutaneous mass “woody”; formation of sinus; & grains containing purulent or seropurulent discharge.

A chronic local, destructive & slowly progressive infection, usually involves the foot.

Begins in subcutaneous tissue, after implantation of vegetative material into tissues.

Then infection spreads to contiguous structures with the sinus tracts and extruding grains.

Disease starts with papule, nodule, or abscess then over months to years progresses slowly & forms multiple abscesses.

Sinus tracts ramifying deep in tissue.

Secondary bacterial infection may result in large open ulcers.

Investigations:

Radiographs- shows destructive changes in underlying bone.

Causative species can often be suggested by the color of the characteristic grains and hyphal size within the infected tissues,

Definitive diagnosis requires culture.

USG, x-ray, MRI.

Infectious cause evaluation- microscopic examination of grains, PCR and sequencing, fine needle aspiration cytology or histology.

Treatment:

Eumycetoma requires surgery (generally large excision or limb amputation may be necessary in advanced cases) and prolonged systemic antifungal treatment. Treatment for > 3 months & yrs in few cases.

itraconazole 200-400 mg/day

voriconazole 400-600 mg/day

posaconazole 200 mg 4 times daily

terbinafine 500-1,000 mg/day

The prognosis for eumycetoma is poor.

Actinomycetoma is easier to treat. Surgery rarely needed.

antibacterial regimens options include- treatment durations (up to 6 mth after sinuses are healed):

Welsh regimen, modified Welsh regimen, 2-step regimen, modified 2-step regimen

medicine used like- sulfamethoxazole/trimethoprim, doxycycline, rifampicin, amikacin, amoxicillin/clavulanic acid, imipenem or meropenem, dapsone, linezolid, etc

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