Treatment of actinomycetoma foot--our experience with ten patients

Successful Treatment of Recalcitrant Actinomycetoma of Gluteal Area with Combined Medical Treatment and Surgical Excision with Graft Reconstruction

Mycetoma, formerly known as Madura foot, is a chronic, localized, gradually increasing in size, granulomatous exogenous infection of the skin and subcutaneous tissue with risks of bone and visceral involvement. It is unevenly found worldwide but it is endemic in tropical and subtropical countries. Two groups of mycetoma exist with similar clinical presentation; eumycetoma due to true fungi, and actinomycetoma due to aerobic bacteria from actinomycomycetes species. Mycetoma is difficult to treat and can lead to serious sequelae including disability, deformity and even death, so early diagnosis and treatment can elicit good results. The diagnosis is made based on a clinical picture of a triad of painless tumefaction, draining sinuses and granules of the causative micro-organism along with direct microscopic examination and histological study. It is very important to distinguish between actinomycetoma and eumycetoma for selecting the therapy. Actinomycetomas generally respond well to antimicrobials compared with eumycetomas, which respond poorly and need a combination of medical and surgical therapy. Bone involvement makes treatment more difficult, keeping surgical amputation as the only choice of treatment. Despite the possibility of a cure with medical treatment alone, treatment failure may occur even with long-term therapy, which necessitates adding surgical intervention to achieve cure. We report a case of gluteal actinomycetoma in an Omani man, treated successfully by combined medical treatment and surgical excision with graft reconstruction after failure of different regimens of antimicrobials.

Mycetoma: A Common Yet Unrecognized Health Burden in Central India

Context:

Mycetoma is a chronic suppurative infective disorder of skin, subcutaneous tissue, fascia, and bones caused by the traumatic inoculation of either fungal (eumycotic) or bacterial (actinomycotic) organisms present in the soil. Triad of tumefaction, discharging sinuses, and grains characterizes the disease.

Aims:

This study was undertaken to study the clinical spectrum and treatment response of mycetoma in central India.

Settings and Design:

It was a retrospective study of clinical and/or biopsy-proven and treated cases of mycetoma from November 2015 to October 2016.

Subjects and Methods:

Medical records of diagnosed and treated mycetoma patients were enrolled retrospectively during November 2015 and October 2016. Case records of patients were evaluated with respect to demographic, clinical, microbiological details, bone involvement, and treatment. Type of therapies and outcome, wherever available, were also assessed.

Statistical Analysis:

Statistical analysis was done using proportion, mean, and percentages.

Results:

Eleven cases (male = 8) were seen during the study period (seven actinomycetoma and four eumycetoma). Foot and lower extremity was the most common site (9/11), whereas upper extremity and forehead were involved in one case each. On culture, the organisms isolated were Phialophora and Fusarium. Modified Welsch regimen was started in six of seven patients with actinomycetoma, whereas one was started on sulfamethoxazole–trimethoprim and a combination of amoxicillin and clavulanic acid therapy. All four cases of eumycetoma were treated with itraconazole. On follow-up, six cases of actinomycetoma cases showed significant improvement. Two cases of eumycetoma showed mild to moderate improvement and one case required surgical intervention. One case each of actinomycetoma and eumycetoma were lost to follow-up.

Conclusion:

Mycetoma has been recognized as a neglected tropical disease by the World Health Organization, recently. There are very few case reports from the central part of India. Prominent case detection in our study emphasizes the need of larger studies to know the extent of disease in this part of India.

Combining two antifungal agents does not enhance survival of Galleria mellonella larvae infected with Madurella mycetomatis

OBJECTIVE

To determine whether combination therapy would improve therapeutic outcome in eumycetoma caused by Madurella mycetomatis.

METHODS

Survival, colony-forming units (CFU), melanisation and histopathology in M. mycetomatis-infected Galleria mellonella larvae treated with amphotericin B, itraconazole, terbinafine or combinations thereof were determined.

RESULTS

Compared to larvae treated with 5% glucose, enhanced survival was obtained when M. mycetomatis-infected larvae were treated with amphotericin B, but not when they were treated with itraconazole or terbinafine. Combination therapy did not increase survival compared to 5% glucose-treated larvae, itraconazole-treated larvae or terbinafine-treated larvae. Compared to amphotericin B monotreatment, a significant decrease in survival was noted when this therapy was combined with either itraconazole or terbinafine. CFU, melanisation and histopathology did not differ between monotherapy, combination therapy or 5% glucose-treated larvae.

CONCLUSIONS

Combining different classes of antifungal agents did not enhance the survival of M. mycetomatis-infected G. mellonella larvae. Instead of improving the therapeutic outcome, combining either itraconazole or terbinafine with amphotericin B resulted in significantly lower survival rates of infected larvae than amphotericin B monotherapy. This experimental study does not provide support for the use of combined amphotericin B and itraconazole, combined itraconazole and terbinafine or combined terbinafine and amphotericin B and should be confirmed in other animal models.

Molecular diagnosis of Actinomadura madurae infection by 16S rRNA deep sequencing

Next-generation DNA sequencing can be used to catalog individual organisms within complex, polymicrobial specimens. Here, we utilized deep sequencing of 16S rRNA to implicate Actinomadura madurae as the cause of mycetoma in a diabetic patient when culture and conventional molecular methods were overwhelmed by overgrowth of other organisms.