maduramycosis

maduramycosis

1. MADURAMYCOSIS P onnilavan

2. HISTORY Gill first described the disease in Madura District - India in 1842. Hence the name Madura foot/Madura mycosis.

3. DEFINITION Madura foot or mycetoma Chronic Slowly Progressive post traumatic infection of subcutaneous tissue usually occurring in foot and rarely in other parts of the body Caused by fungi and bacteria

4. EPIDEMIOLOGY Overall actinomycetoma is more common (60%)than eumycetoma(40%). More common in tropics and subtropics. In India maximum no of mycetoma cases reported in Rajasthan Followed by Tamilnadu. Adult male are usually affected. Maximum incidence 21 to 40 yrs of age. Male :female ratio – 3:1to5:1

5. CAUSES Eumycetoma Madurella mycetomatis, Madurella grisea, Scedosporium, Aspergillus, Fuscarium. Actinomycetoma(filamentous bacteria) Streptomyces, Nocardia. Botryomycosis Staphylococcus aureus.

6. PATHOGENESIS Organism enter through minor trauma in farmers(thorn prick, contaminated soil, walking with barefoot) Begins – small subcutaneous swelling of the foot. Enlarge – burrowing into deeper tissue and tracking to the surface as multiple discharging sinuses(viscid seropurulent fluid containing granules).

7. CLINICAL FEATURES Triad of mycetoma ; Tumour like swelling(tumefaction), Discharging sinuses, Granules.

8. CONTD Start with multiple hard deep seated and fixed papule&nodule soft at centre and form abscess. Abscess rupture – persistently draining fistula. Because of very slow extension – infection spread involving tendons bone, muscles proximally toward the ankle upto leg. Skin may be hypo/hyperpigmented with sign of both healed and active sinuses. Swelling is often firm non tender overlying skin is not erthyematous. Extension to underlying bone give rise to periostitis ostemyelitis Arthritis.

9. LAB DIAGNOSIS Granules and grains are microcolonies of causative agent. Look for colour and consistency of grains(macroscopic). In actinomycotic-grains composed of very thin (less than 1um in diameter) GRAM STAIN. Mycotic lesion-broader and often show septae and chlamydospores(2-6um width) KOH mount. Culture-granules obtained from biopsy best suitable for culture. Fungal(SDA) bacteria (lowenstein jensen media).

10. Histopathological staining. Of granules. eumycetoma-granulomatous relation with palisade arrangement of hyphae and cement substance. actinomycetoma-show granulomatous reaction with filamentous bacteria.

11. ACTINOMYCETOMA EUMYCETOMA

12. DIFFERENTIATING FEATURES CLINICAL MANIFESTATION Eumycetoma Actinomycetoma Tumour Single well defined margin Multiple tumour mass with ill-defined margin Sinuses Appear late few in number Appear early numerous with raised inflamed openings Discharge /granules Serous /blackish/white Purulent/white /red Bone Osteosclerotic Osteolytic

13. RADIOLOGIC FEATURE Early stage—soft tissue granuloma appear as soft tissue shadow with calcification and obliteration of facial plane. Bone scalloping from external pressure seen. Periosteal reaction seen. Late stage-punched out cavities after multiple may appear that have well defined margin. Actinomycetic-cavity small numerous with no defined margin (moth eaten appearance).

14. Usg-differentiate the mycetoma from osteomyelitis tumour. Eumycetoma-sharp hyperechoic focus. Actinomycetoma-fine hyperechoic focus. MRI-dot in circle sign.

15. COMPLICATION Secondary bacterial infection, Local abscess formation, Cellulitis Bacterial and tubercular osteomyelitis, Septic death, Lymphoedema.

16. TREATMENT It’ is important to characterise the etiological agent to determine the nature of infection whether it is bacteria or Fungal and to evaluate the extent of this disease. Specific therapy depend upon the identification of causative agent and determination of drug sensitivity. Therapy should be continued for several month after clinical cure to prevent release. Generally eumycetoma has lesser successful rate than actinomycetona.

17. TREATMENT Eumycetoma – antifungal drug. ketoconazole400mg/day. Itraconazole 200 – 500mg/day. Amphotericin50mg/kg iv daily. Actinomycetoma-Welsh regimen. Amikacin +clotrimazole. Isolated case treated with voriconazole200mgpoBD for several month combined with posaconazole400mg bid. Therapy suggested for one or two years for complete eradication unless adverse effect Warrant the cessation of medication.

18. SURGERY Excision of the affected tissue. Localised mycetoma-can be excised completely without Residual disability. Healthy tissue removed – to prevent recurrence. Extensive surgery-followed by skin grafting (cover large open area). Extensive bone involvement – surgical amputation.

19. PREVENTION It is best accomplished by impacting on the incidence of the traumatic inoculation of causative agent. Wearing of shoes and clothing to protect against the splinter and thorn prick should be stressed. Complication can be prevented by Early identification and treatment of lesion usually with minor surgery and chemotherapy.

20. REFERRENCE Tureks orthopaedics Varshney – essential orthopaedics

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