Clinical epidemiological characteristics of mycetoma in Eastern Sennar locality, Sennar State, Sudan

Hope amidst neglect: Mycetoma Research Center, University of Khartoum. A holistic management approach to achieve the United Nations' Sustainable Development Goals

Mycetoma is a debilitating neglected tropical disease that affects individuals worldwide, particularly in regions where there is poverty and limited health care access. The Mycetoma Research Center (MRC), based in Khartoum, Sudan, provides a sustainable, holistic approach to patient care as the only World Health Organization collaborating center for mycetoma. We describe MRC activities that align with the United Nations' Sustainable Development Goals to control mycetoma in Sudan and globally.

The Mycetoma Research Center, University of Khartoum, Sudan's experience in community engagement initiatives spans 3 decades

Mycetoma profoundly affects marginalised communities, especially in impoverished and remote areas with limited access to healthcare. This chronic and debilitating inflammatory disease highlights the typical issues of neglected tropical diseases (NTDs), such as insufficient attention, funding, and resources, which perpetuate neglect and suffering. Patients often delay seeking medical help, leading to advanced disease stages, severe complications, and lasting disabilities. The lack of medical infrastructure and skilled healthcare professionals worsens the situation, causing delays in diagnosis and inadequate treatment. Engaging affected communities in tailored interventions is essential to tackle these challenges, promote collaboration, raise awareness, and mobilise resources to improve healthcare access and enhance diagnostic and treatment capabilities. Since 1991, the Mycetoma Research Center (MRC) at the University of Khartoum, Sudan, has led community engagement initiatives aimed at improving the quality of life for mycetoma-affected individuals through education, advocacy, and local collaboration. In this communication, the MRC shares its extensive experience in community engagement to benefit mycetoma-affected communities.

An updated list of eumycetoma causative agents and their differences in grain formation and treatment response

SUMMARYIn 2023, the World Health Organization designated eumycetoma causative agents as high-priority pathogens on its list of fungal priority pathogens. Despite this recognition, a comprehensive understanding of these causative agents is lacking, and potential variations in clinical manifestations or therapeutic responses remain unclear. In this review, 12,379 eumycetoma cases were reviewed. In total, 69 different fungal species were identified as causative agents. However, some were only identified once, and there was no supporting evidence that they were indeed present in the grain. Madurella mycetomatis was by far the most commonly reported fungal causative agent. In most studies, identification of the fungus at the species level was based on culture or histology, which was prone to misidentifications. The newly used molecular identification tools identified new causative agents. Clinically, no differences were reported in the appearance of the lesion, but variations in mycetoma grain formation and antifungal susceptibility were observed. Although attempts were made to explore the differences in clinical outcomes based on antifungal susceptibility, the lack of large clinical trials and the inclusion of surgery as standard treatment posed challenges in drawing definitive conclusions. Limited case series suggested that eumycetoma cases caused by Fusarium species were less responsive to treatment than those caused by Madurella mycetomatis. However, further research is imperative for a comprehensive understanding.

Epidemiologic Aspects of Mycetoma in Africa

Mycetoma is a chronic, disabling infection caused by fungi or actinomycetes that affects the disadvantaged rural populations of arid tropical regions. The identification of etiological agents is long, difficult, and often imprecise or unsuccessful. Recently developed molecular methods can be used to identify causal agents at the species level. However, diagnosis can only be implemented in specialized laboratories. For these reasons, the distribution of causal agents in endemic African countries remains approximate. It is known that the pathogenic organisms of mycetoma are present in the environment, introduced as a result of injuries or trauma. There are still unknowns concerning the natural habitats of agents and the mode of infection. A potential association between mycetoma and acacia was uncovered in Sudan, allowing the elaboration of a risk map of the country. A new hypothesis for the mode of contamination involves the intervention of an intermediate host. The first surveys in Sudanese endemic villages gave a higher prevalence than the previous estimates, indicating that the prevalence of mycetoma in endemic African countries has previously been underestimated.

Role of socioeconomic factors in developing mycetoma: Results from a household survey in Sennar State, Sudan

BACKGROUND

Mycetoma is a chronic, progressively destructive disease of subcutaneous tissues and bones caused by certain species of bacteria or fungi. We conducted a cross-sectional community-based study alongside mapping of mycetoma in five administrative units with high mycetoma endemicity in the Eastern Sennar Locality, Sennar State, Sudan.

METHODS

A household survey was administered which included questions about the household members, household characteristics, economic activity and history of mycetoma. A clinical examination was conducted on all members of the household. If mycetoma was suspected, an individual questionnaire was completed collecting demographic, clinical and epidemiological data as well as information on the use of health care and associated costs. Geographical coordinates and photos of the lesions were taken, and the affected persons were referred to the medical centre for confirmation of the diagnosis and treatment. We compared the characteristics of households with confirmed cases of mycetoma with those without confirmed cases, and individuals with confirmed mycetoma with those in whom mycetoma was not confirmed.

RESULTS

In total 7,798 households in 60 villages were surveyed; 515 suspected cases were identified and 359 cases of mycetoma were confirmed. Approximately 15% of households with mycetoma had more than one household member affected by this disease. Households with mycetoma were worse off with respect to water supply, toilet facilities, electricity and electrical appliances compared to the survey households. Only 23% of study participants with mycetoma had sought professional help. Of these, 77% of patients travelled an average of six hours to visit a medical facility. More than half of patients had to pay towards their treatment. The estimated average cost of treatment was 26,957 Sudanese pounds per year (566 US dollars, exchange rate 2018).

CONCLUSIONS

Results of this survey suggest that agricultural practices and reduced access to sanitation and clean water can be risk factors in developing mycetoma. Poor access to health care and substantial financial costs were barriers to seeking treatment for mycetoma.

Individual Risk Factors of Mycetoma Occurrence in Eastern Sennar Locality, Sennar State, Sudan: A Case-Control Study

Mycetoma is a serious chronic subcutaneous granulomatous inflammatory disease that is endemic in tropical and subtropical regions, where it impacts profoundly on patients, families, and communities. Individual-level risk factors for the disease are poorly understood. To address this, a case-control study was conducted based on data collected from 60 villages in Eastern Sennar Locality, Sennar State, Sudan. Based on the presence of swelling in any part of the body, or sinus formation with or without grain discharge evident from the lesion by ultrasound examination, we diagnosed 359 cases of mycetoma. For each case, we included three healthy sex-matched persons, with no evidence of mycetoma, from the same village as the control group (n = 1077). The odds for mycetoma were almost three times higher in individuals in the age group 16–30 years (Adjusted Odds Ratio (AOR) = 2.804, 95% CI = 1.424–5.523) compared to those in age group ≤ 15 years. Other factors contributing to the odds of mycetoma were history of local trauma (AOR = 1.892, 95% CI = 1.425–2.513), being unmarried (AOR = 3.179, 95% CI = 2.339–4.20) and owning livestock (AOR = 3.941, 95% CI = 2.874–5.405). In conclusion, certain factors found to be associated with mycetoma in this study could inform a high index of suspicion for mycetoma diagnosis, which would improve early case detection. Other factors found to be associated could inform the development of an interventional program for mycetoma control in Sudan, including education on healthy farming practices and the risks of puncture wounds for individuals residing in endemic areas. However, this work was conducted in one endemic state, while mycetoma cases occur in all states of Sudan. Replicating this study over a wider area would give a fuller picture of the situation, providing the control program with more comprehensive information on the risk factors for the disease.