|LETTER TO THE EDITOR
|Year : 2013 | Volume
| Issue : 4 | Page : 305-307
Mycetoma caused by Madurella mycetomatis
BV Ramachandra, Anila Sunandini Nayar, Subhashini, Kavya Chennamsetty
Department of Dermatology, Venereology and Leprology, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
|Date of Web Publication||26-Nov-2013|
B V Ramachandra
94-Kirlampudi Layout, Andhra University Outgate Down, Visakhapatnam - 530 017, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ramachandra B V, Nayar AS, Subhashini, Chennamsetty K. Mycetoma caused by Madurella mycetomatis. J NTR Univ Health Sci 2013;2:305-7
Mycetoma is a chronic, localized, slowly progressive disease involving cutaneous, subcutaneous tissue and ultimately bone with a clinical triad of tumefaction of tissues, draining sinuses, and discharge of grains. The causal organisms are fungi for eumycetoma and filamentous bacteria for actinomycetoma. Eumycetoma caused by Madurella mycetomatis is characterized by discharge of black grains representing the microcolonies which are diagnostic of the condition. We report two cases of eumycetoma caused by M. mycetomatis.
First patient, a 45-year-old male, farmer by occupation presented to us with swelling over the inner aspect of upper one-third of left leg since 6 years. Lesions were preceded by thorn prick by 3-4 months following which small painless nodules developed. He observed discharge of black grains from sinuses which developed over the nodules 6 months later. There is no discharge of bony spicules.
On examination of the medial aspect of upper one-third of left leg, nodules ranging from 0.5 to 1.5 cm are present. Three to four sinuses with flat opening onto the skin, discharging serous fluid, and black colored grains are observed [Figure 1]a. Surrounding skin is hyperpigmented and lesion is nontender.
Second patient, an 18-year-old male, farmer by occupation presented with diffuse swelling of right foot associated with discharge of black grains since 2 years. Lesion was preceded by thorn prick at the first interdigital cleft.
|Figure 1: (a) Nodules and sinuses discharging black grains. (b) Multiple subcutaneous nodules and sinuses on dorsum of the foot|
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On examination, diffuse swelling of right foot with multiple subcutaneous nodules on dorsum and sole of the foot are observed. Sinuses with discharge of serous fluid and black grains are seen [Figure 1]b. Surrounding skin is hyperpigmented and the lesion is tender.
Black grains are collected on sterile wet dressing applied overnight and are analyzed. The grains are 2-3 mm in size, brittle, oval to lobulated, black, and easily crushed between two slides. A 10% KOH mount showed mycelial clumps with septate hyphae [Figure 2]a. Gram stain showed no bacteria. Grains are cultured on Sabouraud dextrose agar with gentamycin and are incubated at 27 and 37°C. Growth is seen earlier in the culture incubated at 37°C, mature colonies appearing within 1 week. Colonies are white to grey, heaped, radially folded with wooly texture [Figure 3]a. Reverse of agar showed brown black diffusible pigment [Figure 3]b. Microscopy with lactophenol cotton blue revealed septate hyphae with chlamydospores [Figure 2]b. Growth is identified as M. mycetomatis. Histopathological study showed nonspecific inflammatory infiltrate consisting of lymphocytes in the dermis [Figure 4].
|Figure 2: (a) 10% KOH mount showing mycelial clumps with septate hyphae. (b) Lactophenol cotton blue mount revealing septate hyphae with chlamydospores|
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|Figure 3: (a) White to grey, heaped, radially folded colonies of Madurella mycetomatis on Sabouraud dextrose agar. (b) Reverse of the agar showing brown black diffusible pigment|
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|Figure 4: Histopathology showing nonspecific inflammatory infiltrate consisting of lymphocytes in the dermis|
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Mycetoma also known as Maduramycosis or Madura foot was described by John Gill in 1842 for the first time from south India.  It is a chronic localized infection caused by various species of fungi or actinomycetes residing as saprophytes in soil or on plants, characterized by formation of aggregates of microcolonies of organisms within the abscess. Penetrating injury forms important portal of entry for the organism as in our patients. The entity is frequently encountered in tropics and subtropics where habit of walking bare foot is common. Eumycotic mycetoma was more common in northern India; however, recent trends show an increase in incidence of Actinomycetoma.  Foot is the commonest site followed by the upper extremity, perineum, and scalp.  M. mycetomatis is one of the most common causes of eumycetoma.  Clinically, diagnosis of mycetoma is based on the presence of sinus tracts discharging granules. 
Confirmation of the diagnosis of eumycetoma is by isolation and identification of the fungus.  Colonies of M. mycetomatis are slow growing, flat, and leathery at first, white to yellow, becoming brownish, folded and heaped with age with the formation of aerial mycelia. A diffusible brown pigment is characteristically produced in primary cultures. Two types of conidiation are observed, the first is flask-shaped phialides that bear rounded conidia and the second being simple or branched conidiophores bearing pyriform conidia (3-5 μm) with truncated bases. The optimum temperature for growth of this mould is 37°C. M. mycetomatis can be distinguished from Madurella grisea by growth at 37°C and its inability to assimilate sucrose. Fine needle aspiration cytology, ultrasonography, computed tomography, histology, and immunodiagnosis are also helpful in the diagnosis.  Bone involvement is a major complication and must be investigated by radiology.  Radiological analysis of the lesional site in our cases showed no bone involvement. Secondary bacterial infections pose a major threat to patients suffering from eumycetoma, subsequently increasing the disability and pain. Management of eumycetoma is a therapeutic challenge and demands long-term antifungal therapy in spite of which the relapse rates are high. Both the patients are started on oral itraconazole 200 mg twice a day and are in the midway of follow-up with a very good preliminary clinical response. We report these cases in view of increasing frequency of mycetoma caused by M. mycetomatis. The significance of identification of the organism which facilitates specific management with antifungals is highlighted.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]