Eumycetoma: A Clinical Overview

Eumycetoma:
A Clinical Overview
Presenter: Michael Stephen Bolton
Definitions
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• Eumycetomapresentsasalocalized,chronic
granulomatousmycoticinfectionofcutaneousand
subcutaneoustissue.Inprogressivecasesbone,andlymph
nodesarecompromised.Theetiologicbasisofinfectionis
viahyalineandpigmentedmouldsmostcommonlyfoundin
soil.*Usuallybecauseofpoorhygieneandtraumathese
agentsareinoculatedviadirectcontact.
• Endemicregionsaretypicallytropicandsubtropicareas.
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Note area between redlines specifically areas shaded with red dots denotes high concentration of fungi species.
Sudan a highly endemic region Graphic taken from University of Khartoum I.E.D
Taken from Atlas of Fungal Infections Carol A Kaufman 2ed : Springer
Note: distal appendages mostly infected.
Case Report 1
• Medscape General Medicine. 2004;6(2):55. ©2004
• CC:38 year old male presented with a swollen, draining right
foot.
• History of Illness: In 1987, A growth developed between 4th &
5th digit in foot and painless edema (swelling).
• Pt. went to another hospital, diagnosed w/ fungal infection and
underwent unknown operation.
• Edema resolved following procedure.
Case Report 1 (cont.)
• In June 2001, symptoms resumed, characterized by distal
edema and pain.
• Localized to lateral right foot
• Informed that x-ray revealed “dislocation”
And Pt. foot placed in a cast for 1 month.
• Upon removal condition progressed to:
• Discharging pus & Black Granules
• Pt had difficulty walking
Case Report 1 (cont.)
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Review of systems: Unremarkable, no fever
Past Medical History: 1987 & 2001
Medications: Zero
Family History: Noncontributory.
Social History: Native Kenyan farmer, works w/o shoes.
Physical Examination: Bp 100/60mm Hg, P 74, RR 18, Tmax 36.5,
Right Foot: edematous non tender. Multiple draining sinus tracts
discharging frank pus and black cuboid granules. No
lymphadenopathy palpable.
Figure 1. Multiple sinuses were present on the right foot.
Medscape General Medicine. 2004;6(2):55. ©2004
Figure 2. Black, cuboid granules discharged via sinuses.
Medscape General Medicine. 2004;6(2):55. ©2004
Case Report 1 (cont.)
• Diagnostic and Surgical Findings
• X-ray: osteolysis, midtarsal joint destruction
• Distal incisions: sinus tracts contained black granules and
granulation tissue (consistent with eumycetoma.
• Figure 3: Discrete collections of fungal organisms.
• Figure 4: Thick walled Chlamycdoconidia
• Pathological findings consistent with eumycotic mycetoma
“Madura Foot”
Medscape General Medicine. 2004;6(2):55. ©2004
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Micro examination of black granule removed from the ulcer bed. On a background of fibrotic and inflammatory tissue could be seen discrete
collections of fungal organisms. Procedure Diagnostic.
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Medscape General Medicine. 2004;6(2):55. ©2004
Close-up of fungal pathogen showing thick-walled chlamydoconidia.
Case Report 1 (cont.)
• Diagnosis
• Morphology most closely resembled either Curvularia
geniculata or Leptosphaeria senegalensis.*Unable to culture
due to lack of facilities.
• Pathological and Clinical findings consistent with eumycotic
mycetoma, commonly referred to as “Madura Foot”
Case Report 1 (cont.)
• Treatment: Pt. discharged w/o specific medical therapy
• A review of literature w/ regard to species and availabilty
suggests that a combination of surgical excision and anti
fungal is standard and appropriate.*
• Ketoconazole, Amphorectin B & Terbinafine
(Administered over long periods of time)
• Ketoconazole is available in Kenya
• Pt scheduled for 1 month follow up, yet to date has not
returned to hospital
Case Report 2
• Journal de Mycologie Medicale 16 (2006) 173-176
• Eumycetoma not endemic to Morocco. (i.e. Rare)
• CC: Ahmed 47yr old male presenting w/ Fistulated tumefaction,
localised to left popliteal space.
• Pt. started w. small nodule above knee 12yrs ago, nodule surgically
removed. yet no histopathology was done(not diagnosed as
infection and treated.)
Case Report 2 (cont.)
• Ze facts…
• Pt. radiology data normal, Inflammation due to presence of black grains suspected fungal origin
• Mycological exam of grains provides solid diagnosis, after culturing fungi confirms a case of Madurella
Mycetomatis
• Out of 44 cases reported since 1960 only four (isolated) observed to be M.mycetomatis.*
• Major Tunisian study of 13 cases six of the pathologies were of fungal origin and 3 observed to be
M.mycetomatis.*
• Typically eumycetoma Tropical and Rural not Arrid and Urban*
• 2 hypothesis: * innoculated poor surgical hygeine or * classic direct cutaneous trauma.
• La lesion initiale du mycetome fongique est un nodule sous-cutane indolore evoluant
progressivement.*
Case Report 2 (cont.)
• Review of systems:
• Past Medical History: 1993 presented w/ new nodule left popliteal,
painless “indolore” , 1995 surgically treated, no Histopatho exam
• Medications: none
• Family History: non contributory
• Social History: Native Moroccan, Larache hometown is urban and
1hr north of Rabat.
• Physical Examination: Focused primarily on CC, (Left Knee,
Popliteal Space)
Case Report 2 (cont.)
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Journal de Mycologie Médicale 16 (2006) 174 Figure 1 Eumycetoma : inflammatory fistulated tumor.
Au moment de l’examen, le patient présentait une masse prenant tout le creux poplité gauche, gênant la marche, polyfistulisee avec
une peau en regard fine rouge et violacée, mesurant 15 × 20 cm, adhérente aux plans superficiel et profond.*
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Journal de Mycologie Médicale 16 (2006) 174 Figure 2 Fungal grains.
hématique contenant des petits grains de couleur noir
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Journal de Mycologie Médicale 16 (2006) 174 des filamentés septes de 2 -5 匸m de diamètre présentant des dilatations terminales
donnant un aspect de vésicules.
Figure 3 Examen direct d’un grain fongique (× 400).
Case Report 2 (cont.)
Case Report 2 (cont.)
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Case Report 2 (cont.)
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Journal de Mycologie Médicale 16 (2006) 174
Figure 4 Culture de Madurella mycetomatis sur Sabouraud. L’incubation avait duré environ trois semaines a 37 䡓C et un mois
a 25 䡓C
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Journal de Mycologie Médicale 16 (2006) 175 Microscopique view showing pigmented filaments containing chlamydoconidia.
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Figure 5 (6) Filaments mycéliens septes contenant de nombreuses chlamydospores.
(x 400). Septated Hyphae
Case Report 2 (cont.)
Case Report 2 (cont.)
• Diagnosis and Lab Findings
• Madurella Mycetomatis (species)
• Black Grains (eumycetoma)
• Fungi morphology: septae hyphae and numerous
chlamydoconidia
• Initial nodule progressed to fistula
• Cultured on Sabouraud Agar 3weeks @ 37 celsius, and 1
month at 25 celsius
Case Report 2 (cont.)
• Treatment Plan & Follow Up
• Pt. placed on Ketoconazole 400mg(1yr)
• Treatment in conjunction w/ Surgical excision to remove
tumor.*(Most Effective)
• Resolved after 4 months(favorable)
• Treatment was designed relative to *volume of tumor (15 x
20cm)
• Pt. should be followed for up to 3yrs*
• Since last appt, Pt “lost and has not been seen”
References
• Abdalla O, Leeuwen WV, Fahal A, Van de Sande W. Verburgh H, Van Belkum A. Mycetoma
caused by Madurella mycetomatis: a neglected infectious burden. Lancet Infect Dis 2004;
4:566-74
• Develoux M, Dieng MT, Kane A, Ndiaye B. Pris en charge des mycetomes en Afrique de
L’Ouest. Bull Soc Pathol Exot 2003; 96:376-82
• Kallel K, Belhaj S, Karabaka A, Kaouch A, Ben Osman-Dhahri A, Ben Chaabane T, et al.
Qu’en est il des mycetomes en Tunisie? A propos de 13 ca colliges en 13 ans. J Mycol Med
2005; 15:56-60
• Welsh O, Salinas MC, Rodriguez MA. Traitment of eumycetoma and actinomycetoma. Curr
Top Med Mycol 1995;6:47-71
References Cont.
• Chandler FW, Ajello L. Mycetoma. In: Chandler FW, Connor DH, Schwartz DA, et al, eds. Pathology of
Infectious Diseases. Vol 2. Appleton & Lange: Stamford, Conn: Appleton & Lange; 1997:1035-1044.
• Pierce NF, Millan JC, Bender BS, Curtis JL. Disseminated Curvularia infection. Additional therapeutic
and clinical considerations with evidence of medical cure. Arch Pathol Lab Med. 1986;110:959-96
• Atlas of Fungal Infection, Mandell, Gerald L. Kauffman, Carol A (Ed) 2nd ed. 2007;pp 243-265
• http://www.pubmedcentral.nih.gov/ Accessed June 7th -11th 2007
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www.doctorfungus.org Accessed June 7th, 8th & 9th 2007
www.medscape.com Accessed June 7-9th 2007
http://plantbio.berkeley.edu/~taylor/pmb110/generallinks.html
Accessed June 2007
http://tomvolkfungi.net/ Accesed June 2007
[email protected]