Eumycetoma

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Eumycetoma
Other namesMadura foot [1]
Madura foot..JPG
An infected foot
Specialty Infectious disease [2]
Symptoms Swelling, weeping pus filled sinuses, deformity. [3]
Complications Amputation
Causes Madurella spp., Leptosphaeria senegalensis , Curvularia lunata , Pseudallescheria spp., Neotestudina rosatii , Acremonium spp. and Fusarium spp. [2]
Diagnostic method Microscopy, biopsy, culture, [3] medical imaging, ELISA, immunodiffusion, DNA sequencing [4]
Differential diagnosis Actinomycosis (Actinomycetoma) [3]
Treatment Surgical debridement, antifungal medicines [3]
Medication Itraconazole, posaconazole, voriconazole [4]
Prognosis Recurrence is common [5]
FrequencyEndemic in Africa, India and South America [3]

Eumycetoma, also known as Madura foot, [1] [6] is a persistent fungal infection of the skin and the tissues just under the skin, affecting most commonly the feet, although it can occur in hands and other body parts. [5] It starts as a painless wet nodule, which may be present for years before ulceration, swelling, grainy discharge and weeping from sinuses and fistulae, followed by bone deformity. [3]

Contents

Several fungi can cause eumycetoma, [5] including: Madurella mycetomatis , Madurella grisea , Leptosphaeria senegalensis , Curvularia lunata , Scedosporium apiospermum , Neotestudina rosatii , and Acremonium and Fusarium species. [2] Diagnosis is by biopsy, visualising the fungi under the microscope and culture. [5] Medical imaging may reveal extent of bone involvement. [4] Other tests include ELISA, immunodiffusion, and DNA Barcoding. [4]

Treatment includes surgical removal of affected tissue and antifungal medicines. [3] After treatment, recurrence is common. [5] Sometimes amputation is required. [5]

The infection occurs generally in the tropics, [7] and is endemic in Sub-Saharan Africa, especially Sudan, India, parts of South America and Mexico. [3] Few cases have been reported across North Africa. [8] [9] Mycetoma is probably low-endemic to Egypt with predilection for eumycetoma. [10] In 2016, the World Health Organization recognised eumycetoma as a neglected tropical disease. [7]

Signs and symptoms

Madura foot Madura foot me photo for help in diagnosis.jpg
Madura foot

The initial lesion is a small swelling under the skin following minor trauma which breaches the skin. [11] [12] It appears as a painless wet nodule, which may be present for years before ulceration, swelling and weeping from sinuses, followed by bone deformity. [3] [7] The sinuses discharge a grainy liquid of fungal colonies. [11] These grains are usually black or white. [13] Destruction of deeper tissues, and deformity and loss of function in the affected limbs may occur in later stages. [14] It tends to occur in one foot. [13] Mycetoma due to bacteria has similar clinical features. [15]

Causes

Eumycetoma is a type of mycetoma caused by fungi, distinct from mycetoma caused by bacteria from the phylum Actinomycetes; [11] [12] both have similar clinical features. [15]

The most common fungi causing white discharge is Pseudallescheria boydii . [13] [16] Other causative agents of non-black grain eumycetoma include Acremonium and Fusarium species. [13]

Black discharge tends to be caused by species from the genera Madurella , Pyrenochaeta , Exophiala , Leptosphaeria and Curvularia . [13] The most common species are Madurella mycetomatis [13] [17] and Trematospheria grisea (previously called Madurella grisea ). [13] [18]

Other fungal causative agents include:

Mechanism

Madura foot section Tropical Diseases - Fig 206.png
Madura foot section

The disease is acquired by entry of the fungal spores from the soil through a breach in the skin produced by minor trauma like a thorn prick. [21] The disease then spreads to deeper tissues and also forms sinus tracts leading to skin surface. [12] Mature lesions are characterised by a grainy discharge from these sinuses. These discharges contain fungal colonies and are infective. Spread of infection internally through blood or lymph is uncommon.[ citation needed ]

Infections that produce a black discharge mainly spread subcutaneously. In the red and yellow varieties deep spread occurs early, infiltrating muscles and bones but sparing nerves and tendons, which are highly resistant to the invasion. [22]

Botryomycosis, also known as bacterial pseudomycosis, produces a similar clinical picture and is caused usually by Staphylococcus aureus . [23] Other bacteria may also cause botryomycosis. [24]

Diagnosis

Diagnosis is by biopsy, visualising the fungi under the microscope and culture, which show characteristic fungal filaments and vesicles characteristic of the fungi. [5] Other tests include ELISA, immunodiffusion, and PCR with DNA sequencing (so-called DNA barcoding). [4]

X rays and ultrasonography may be carried out to assess the extent of the disease. X rays findings are extremely variable. The disease is most often observed at an advanced stage that exhibits extensive destruction of all bones of the foot. Rarely, a single lesion may be seen in the tibia where the picture is identical with chronic osteomyelitis. Cytology of fine needle aspirate or pus from the lesion, and tissue biopsy may be undertaken sometimes. [11] Some publications have claimed a "dot in a circle sign" as a characteristic MRI feature for this condition (this feature has also been described on ultrasound). [14]

Madura Foot X-Ray Madura foot x-ray.JPG
Madura Foot X-Ray

Differential diagnosis

The following clinical conditions may be considered before diagnosing a patient with mycetoma:[ citation needed ]

  1. Tuberculous ulcer
  2. Kaposi's sarcoma, a vascular tumour of skin usually seen in AIDS.
  3. Leprosy
  4. Syphilis
  5. Malignant neoplasm
  6. Tropical ulcer [22]
  7. Botryomycosis, [12] a skin infection usually caused by the bacteria Staphylococcus aureus.

Prevention

No vaccine is available. Simple hygienic precautions like wearing shoes or sandals while working in fields, and washing hands and feet at regular intervals may help prevent the disease.[ citation needed ]

Treatment

Surgery combined with itraconazole may be given for up to year when the grains are black. [4] Posaconazole is another option. [4] Voriconazole can be used for infections caused by Fusarium species. [4]

Ketoconazole has been used to treat eumycetoma but has many side effects. [25] Actinomycetes usually respond well to medical treatment, but eukaryotic infections are generally resistant and may require surgical interventions including salvage procedures as bone resection or even the more radical amputation. [26] [12] [14]

Oral fosravuconazole, which is much cheaper than itraconazole, an important factor as eumycetoma mainly affects young adults in poorer, rural areas, was found in 2023 in Phase II clinical trials to be safe, patient-friendly, and effective in treating eumycetoma. [27] [28]

Epidemiology

The disease is more common in males aged 20–40 years who work as labourers, farmers and herders, and in travellers to tropical regions, where the condition is endemic. [4]

History

Madura foot or maduromycosis or maduramycosis [29] is described in ancient writings of India as Padavalmika, which, translated means Foot anthill. [12] The first modern description of Madura foot was made in 1842 from Madurai (the city after which the disease was named Madura-mycosis) in India, by Gill. [12] The fungal cause of the disease was established in 1860 by Carter. [12]

Society and culture

In 2016, the World Health Organization recognised eumycetoma as a neglected tropical disease. [7] Traditionally occurring in regions where resources are scarce, medicines may be expensive and diagnosis is frequently made late, when more invasive treatment may be required. [7]

Related Research Articles

<span class="mw-page-title-main">Fungal infection</span> Disease caused by fungi to animals or humans

Fungal infection, also known as mycosis, is a disease caused by fungi. Different types are traditionally divided according to the part of the body affected; superficial, subcutaneous, and systemic. Superficial fungal infections include common tinea of the skin, such as tinea of the body, groin, hands, feet and beard, and yeast infections such as pityriasis versicolor. Subcutaneous types include eumycetoma and chromoblastomycosis, which generally affect tissues in and beneath the skin. Systemic fungal infections are more serious and include cryptococcosis, histoplasmosis, pneumocystis pneumonia, aspergillosis and mucormycosis. Signs and symptoms range widely. There is usually a rash with superficial infection. Fungal infection within the skin or under the skin may present with a lump and skin changes. Pneumonia-like symptoms or meningitis may occur with a deeper or systemic infection.

Actinomycetoma is a chronic bacterial subcutaneous infection caused by Actinomyces that affect the skin and connective tissue. It is, therefore, a form of actinomycosis. Mycetoma is a broad term which includes actinomycetoma and eumycetoma under it. However, eumycetoma is caused by fungal infection in contrast to actinomycetoma that is caused by mostly anaerobic bacteria. The predominant site of infection is the foot and leg. Both actinomycetoma and eumycetoma show very similar clinical and radiological presentations and are endemic in tropical countries.

A skin infection is an infection of the skin in humans and other animals, that can also affect the associated soft tissues such as loose connective tissue and mucous membranes. They comprise a category of infections termed skin and skin structure infections (SSSIs), or skin and soft tissue infections (SSTIs), and acute bacterial SSSIs (ABSSSIs). They are distinguished from dermatitis, although skin infections can result in skin inflammation.

Fungal keratitis is a fungal infection of the cornea, which can lead to blindness. It generally presents with a red, painful eye and blurred vision. There is also increased sensitivity to light, and excessive tears or discharge.

<span class="mw-page-title-main">Aspergillosis</span> Medical condition

Aspergillosis is a fungal infection of usually the lungs, caused by the genus Aspergillus, a common mould that is breathed in frequently from the air, but does not usually affect most people. It generally occurs in people with lung diseases such as asthma, cystic fibrosis or tuberculosis, or those who are immunocompromized such as those who have had a stem cell or organ transplant or those who take medications such as steroids and some cancer treatments which suppress the immune system. Rarely, it can affect skin.

<span class="mw-page-title-main">Conidiobolomycosis</span> Fungal infection

Conidiobolomycosis is a rare long-term fungal infection that is typically found just under the skin of the nose, sinuses, cheeks and upper lips. It may present with a nose bleed or a blocked or runny nose. Typically there is a firm painless swelling which can slowly extend to the nasal bridge and eyes, sometimes causing facial disfigurement.

<i>Cochliobolus lunatus</i> Fungal plant pathogen

Cochliobolus lunatus is a fungal plant pathogen that can cause disease in humans and other animals. The anamorph of this fungus is known as Curvularia lunata, while C. lunatus denotes the teleomorph or sexual stage. They are, however, the same biological entity. C. lunatus is the most commonly reported species in clinical cases of reported Cochliobolus infection.

Exophiala jeanselmei is a saprotrophic fungus in the family Herpotrichiellaceae. Four varieties have been discovered: Exophiala jeanselmei var. heteromorpha, E. jeanselmei var. lecanii-corni, E. jeanselmei var. jeanselmei, and E. jeanselmei var. castellanii. Other species in the genus Exophiala such as E. dermatitidis and E. spinifera have been reported to have similar annellidic conidiogenesis and may therefore be difficult to differentiate.

<i>Madurella</i> Genus of fungi

Madurella is a fungal genus of Hyphomycetes, of uncertain position in the Sordariales, and sometimes classified as Mitosporic Ascomycota.

<i>Madurella grisea</i> Species of fungus

Madurella grisea is a fungal species of the genus Madurella. Along with Exophiala jeanselmei, Madurella grisea is one of the most common pathogenic agents associated with eumycetoma.

Pathogenic fungi are fungi that cause disease in humans or other organisms. Although fungi are eukaryotic, many pathogenic fungi are microorganisms. Approximately 300 fungi are known to be pathogenic to humans; their study is called "medical mycology". Fungal infections kill more people than either tuberculosis or malaria—about 2 million people per year.

<i>Pseudallescheria boydii</i> Species of fungus

Pseudallescheria boydii is a species of fungus classified in the Ascomycota. It is associated with some forms of eumycetoma/maduromycosis and is the causative agent of pseudallescheriasis. Typically found in stagnant and polluted water, it has been implicated in the infection of immunocompromised and near-drowned pneumonia patients. Treatment of infections with P. boydii is complicated by resistance to many of the standard antifungal agents normally used to treat infections by filamentous fungi.

Mycetoma is a chronic infection in the skin caused by either bacteria (actinomycetoma) or fungi (eumycetoma), typically resulting in a triad of painless firm skin lumps, the formation of weeping sinuses, and a discharge that contains grains. 80% occur in feet.

<span class="mw-page-title-main">Richard Summerbell</span> Canadian mycologist (born 1956)

Richard C. Summerbell is a Canadian mycologist, author and award-winning songwriter. He was editor in chief of an international scientific journal in mycology from 2000 to 2004. In the 1970s and 80s, he was a gay activist and an early commentator on (then) controversial topics such as AIDS and promiscuity and attitudes to homosexuality in organized religion.

Phaeohyphomycosis is a diverse group of fungal infections, caused by dematiaceous fungi whose morphologic characteristics in tissue include hyphae, yeast-like cells, or a combination of these. It can be associated an array of melanistic filamentous fungi including Alternaria species,Exophiala jeanselmei, and Rhinocladiella mackenziei.

Scedosporiosis is the general name for any mycosis - i.e., fungal infection - caused by a fungus from the genus Scedosporium. Current population-based studies suggest Scedosporium prolificans and Scedosporium apiospermum to be among the most common infecting agents from the genus, although infections caused by other members thereof are not unheard of. The latter is an asexual form (anamorph) of another fungus, Pseudallescheria boydii. The former is a “black yeast”, currently not characterized as well, although both of them have been described as saprophytes.

<i>Madurella mycetomatis</i> Species of fungus

Madurella mycetomatis is a fungus primarily reported in Central Africa as a cause of mycetoma in humans. It has been misclassified for many years, but with improvement of molecular techniques, its phylogenetic classification has been established. Many methods exist to identify M. mycetomatis, both in lesions and in culture. Histological examination is especially useful, as it has many unique morphological features. Strain-level differences in response to antifungal agents is informative for treatment and laboratory isolation of cultures.

Sarocladium kiliense is a saprobic fungus that is occasionally encountered as a opportunistic pathogen of humans, particularly immunocompromised and individuals. The fungus is frequently found in soil and has been linked with skin and systemic infections. This species is also known to cause disease in the green alga, Cladophora glomerata as well as various fruit and vegetable crops grown in warmer climates.

Curvularia geniculata is a fast-growing anamorphic fungus in the division Ascomycota, most commonly found in soil, especially in areas of warmer climates. The fungus is a pathogen, mainly causing plant and animal infections, and rarely causing human infections. C. geniculata is characterized by its curved conidia, which has a dark brown centre and pale tapered tips, and produces anti-fungal compounds called Curvularides A-E.

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