Annals of Tropical Medicine and Public Health

CASE REPORT
Year
: 2012  |  Volume : 5  |  Issue : 4  |  Page : 352--354

Mycetoma foot due to Madurella mycetomatis


Archana B Wankhade, Dnyaneshwari P Ghadage, Rupali J Mali, Arvind V Bhore 
 Department of Microbiology, Smt. Kashibai Navale Medical College and Hospital, Narhe, Pune, India

Correspondence Address:
Archana B Wankhade
Department of Microbiology, Smt Kashibai Navale Medical College and Hospital, STES Narhe Campus, Narhe Ambegaon, Pune - 411 041
India

Abstract

Mycetoma is chronic granulomatous infection. The causative agents are fungi and bacteria. We report a case of mycetoma in 19-years-old college student having history of thorn prick on left foot. Madurella mycetomatis was isolated from the granular discharge from sinuses surgical debridement with intralesional amphotericn therapy was given.



How to cite this article:
Wankhade AB, Ghadage DP, Mali RJ, Bhore AV. Mycetoma foot due to Madurella mycetomatis.Ann Trop Med Public Health 2012;5:352-354


How to cite this URL:
Wankhade AB, Ghadage DP, Mali RJ, Bhore AV. Mycetoma foot due to Madurella mycetomatis. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Sep 18 ];5:352-354
Available from: http://www.atmph.org/text.asp?2012/5/4/352/102054


Full Text

 Introduction



Mycetoma is a chronic, granulomatous, subcutaneous, inflammatory disease caused by true fungi (eumycetoma) or filamentous bacteria (actinomycetoma). Eumycetoma usually affects adult males involving limbs and other exposed body parts. Mycetoma due Madurella mycetomatis is diagnosed by clinician, and the organism was isolated from the discharging granules from the sinuses of foot.

 Case Report



A female patient aged 19-year came with complaints of swelling on left foot with multiple sinuses discharging black granules. She was a student. She had given history of thorn prick 3 years back. After 1 year, single nodular small swelling at the site of prick was observed. Gradually, the swelling increased, and after 4-5 months, the discharging sinuses developed on the swelling. The granular discharge increased gradually with time.

On examination, the foot was swollen with black discoloration of skin over foot. There were 3 to 4 sinuses over foot. The sinuses were with flat opening and were discharging serous fluid with black-colored granules. The foot was not disfigured and was non-tender. The granules were easily visible on the undersurface of the dressing pad.

The sterile dressing pad having discharge with abundant black granules were submitted in microbiology laboratory. The granules were transferred in the sterile Petri dish. The granules were washed with sterile normal saline 4 to 5 times. On gross examination, the grains were 0.5-1 mm brittle, oval-lobed, and black. The single grain was crushed easily between two slides. With one slide, 10% KOH mount was prepared and with other, gram stain was done. In gram stain, no bacteria were seen. In 10% KOH mount, the mycelia clumps with septate pheoid hyphae were seen [Figure 1]. The culture was done on two sets of plain Saborourds dextrose agar (SDA), SDA with chloramphenicol and SDA with cyclohexamide. One set was incubated at 27 o C and one set at 37 o C. Lowenstein Jensen, blood agar were also inoculated and incubated at 37 o C. It grew at both temperature, but growth was seen early at 37 o C, and colonies matured within one week. At 27 o C, the growth was slow. The colony matured in two weeks. Macroscopically, the surface colony raised to heaped, radially folded with glabrous to wooly texture; color white to yellow - brown to dark gray or olive brown while the reverse with the production of a brown diffusible pigment [Figure 2]. The growth was also seen on LJ medium, which was incubated at 37 o C. Exposure at 37°C leads to an optimum growth of Madurella mycetomatis while Madurella grisea grows poorly or does not grow at all at this temperature. Microscopic morphology in Lactophenol blue preparation revealed septate hyphae with lateral phailides [Figure 3]. Round to oval conidia were also seen. The growth was identified as Madurella mycetomatis{Figure 1}{Figure 2}{Figure 3}

 Discussion



Subcutaneous mycosis is a chronic fungal infection of the skin and subcutaneous tissues characterized by tumefaction, abscess formation, draining sinuses, and presence of grains within the abscesses and fistulae. Madurai (South India) as madhura foot, but now it is known to be prevalent in other countries also. Foot is the commonest site followed by the upper extremity. Involvement of the perineum is third in order of frequency, and the fourth commonest site is scalp. [1] The etiological factors involved in causation are multiple in the form of thorn prick, trauma leading to ulceration, blunt trauma, and wicks. The clinical picture of Mycetoma is almost uniform irrespective of the causative fungi. [2] Madurella mycetomatis is known to be one of the most common causes of eumycetoma. [3] Adult males with more outdoor activity are the usual victims of this disease, commonly involving areas like limbs and other exposed body parts. Clinically, diagnosis of mycetoma is made on the basis of presence of sinus tracts, or characteristic of discharging granules; however, this was a typical presentation of maduromycosis marked by the presence of black grains in the pus, or any overlying sinus tracts. [3]

Confirmation of diagnosis of eumycetoma is based on isolation and identification of fungus in microbiology laboratory. [4] In most of the cases, more sophisticated tests are not required and routine fungal culture and histology is sufficient. Techniques such as fine needle aspiration cytology, ultrasonography, computed tomography, histology, or immunodiagnosis are also very helpful in diagnosis. [5] Bone involvement is a major complication and must be investigated by radiology. [6] An X-ray of the present case foot showed ostesclerotic lesions and not encroached up to bone. Secondary, bacterial infections pose a major threat to the patients suffering from eumycetoma; subsequently increasing the disability and pain. Treatment of eumycetoma is difficult and poses a challenge and may include long term anti-fungal therapy; however, the relapse rates are higher.

Trimethoprim sulpamethoxazole and intralesional amphotericin were given on alternate day for two months with surgical debridement. The patient is still being followed up. The etiological factors involved in causation are multiple in the form of thorn prick, trauma leading to ulceration, blunt trauma, and the wicks. The clinical picture of Mycetoma is almost uniform irrespective of the causative fungi. [7] In addition, there are large problems with the correct identification of M. mycetomatis. It shows poor morphological differentiation and causes confusion among clinicians and microbiologists. [8]

References

1McGinnis MR. Mycetoma. Dermatol Clin 1996;14:97-104.
2Singh H. Perianal Mycetoma. Indian J Surg 1976;38:530-4.
3Fahal AH. Mycetoma: A thorn in the flesh. Trans R Soc Trop Med Hyg 2004;98:3-11.
4Develoux M, Dieng M T, Kane A, Ndiaye B. Management of mycetoma in West-Africa. Bull Soc Pathol Exot 2003;96:376-82.
5Rao GM, Devanandam K, Janaki M, Lakshmireddy K. Unusual sites of mycetoma. Indian J Surg 2004;66:46-7.
6Mancini N, Ossi CM, Perotti M, Clementi M, Digiolo DB, Schaenman JM, et al. Molecular mycological diagnosis and correct antimycotic treatments. J Clin Microbiol 2005;43:3584-5.
7Ahmed AO, Mukhtar MM, Kools-Sijmons M, Fahal AH, de Hoog S, van den Ende BG, et al. Development of a species-specific PCR-restriction fragment length polymorphism analysis procedure for identification of Madurella mycetomatis. J Clin Microbiol 1999;37:3175-8.
8de Hoog GS, Buiting A, Tan CS, Stroebel AB, Ketterings C, de Boer EJ, et al. Diagnostic problems with imported cases of mycetoma in The Netherlands. Mycoses 1993;36:81-7.