CASE REPORT |
https://doi.org/10.5005/jp-journals-10079-1110 |
Eumycetoma Infection of Foot: A Rare Case Report
1-3Department of Orthopedics, Dr. Muthus Superspeciality Orthopedic Hospital, Coimbatore, Tamil Nadu, India
Corresponding Author: Yogadeepan Dhakshinamurthi, Department of Orthopedics, Dr. Muthus Superspeciality Orthopedic Hospital, Coimbatore, Tamil Nadu, India, Phone: +91 9952437518, e-mail: yogadeepan5992@gmail.com
Received on: 26 November 2022; Accepted on: 28 November 2022; Published on: 03 January 2023
ABSTRACT
Introduction: Euycetoma infection is a rare and debilitating progressive chronic granulomatous disease. It has serious economical, medical, and social impacts on the people.
Case description: A 30-year-old gentleman came with complaints of swelling with blackish discoloration of his right foot for the past 10 years. He was clinically and through biopsy proven to be an eumycetoma infection of the foot. He underwent radical excision followed by vacuum dressing and split skin grafting of the foot. The wound healed completely and there was no recurrence over a follow-up period of 6 months.
Conclusion: Early and appropriate diagnosis and management are necessary for optimal treatment and to prevent a recurrence.
Clinical significance: Diagnosis of eumycetoma infection is predominantly through clinical examination and history. It has to be differentiated from actinomycetal infection. Chronic history, long incubation period, and painless swelling are its salient features.
How to cite this article: Dhakshinamurthi Y, Meignanaguru M, Shetty GR. Eumycetoma Infection of Foot: A Rare Case Report. J Orth Joint Surg 2023;5(1):33–36.
Source of support: Nil
Conflict of interest: None
Keywords: Antifungals, Eumycetoma, Split skin graft
BACKGROUND
Eumycetoma is a chronic disorder of granulomatous infection. It is a disease of subcutaneous tissue, skin, and bones. Most commonly affects the bones of the foot; careful history-taking is vital, since the majority of patients have previous trivial injuries with vegetative matters/agricultural products. If not detected early, it can cause disabling deformity of the limbs, occupation loss, and accelerates the rate of dropouts from school in children.1 It also severely impacts a patient’s functional disability when treated late. The rarity of the disease and delayed presentation account for the deficient data available about the disease.
CASE DESCRIPTION
A 30-year-old gentleman came with complaints of swelling along with blackish discoloration of his right foot for the past 10 years with occasional blackish discharge on and off. He is a farmer and a regular barefoot walker. A previous history of thorn prick injury over his right foot 10 years back.
On clinical examination, multiple lobulated swelling with sinuses over the dorsum of the foot. Blackish discoloration of the foot is present, skin is thickened, and adherent to the underlying tissues. Swelling soft to firm in consistency, minimal tenderness on palpation present. Neurological status, toe movements, and distal pulses are intact (Fig. 1).
Figs 1A to C: Clinical picture
The patient’s X-ray of the foot was normal and his blood parameters were within normal limits (Fig. 2).
Fig. 2: X-ray
The patient underwent a biopsy and culture of the lesion under regional anesthesia under strict aseptic precautions. The biopsy report came as eumycetoma (Figs 3 to 5).
Fig. 3: Biopsy report
Fig. 4: Slide report
Fig. 5: Culture report
The patient underwent radical excision of the lesion under spinal anesthesia. During excision, many fungal black colonies were found in the subcutaneous plane extending into the region where the above skin was normal. Paratenon and bone were not involved. Careful dissection was done to ensure the tendon sheath was not damaged (Figs 6 to 7).
Figs 6A and B: Intraoperative picture
Fig. 7: Postradical excision
After radical excision patient underwent vacuum dressing for 5 days to ensure a good granulation bed was there for soft tissue cover (Fig. 8).
Fig. 8: Postvacuum dressing
The patient underwent debridement and split skin grafting and was started on an antifungal (fluconazole 500 mg twice daily). Antibiotics also started to ensure no secondary bacterial infection happens. The patient skin graft healed completely and the patient had no recurrence for a follow-up of 6 months (Figs 9 to 11).
Fig. 9: Post-split skin grafting
Fig. 10: About 2 weeks follow-up
Fig. 11: Around 1-year follow-up
DISCUSSION
Eumycetoma is characterized by a triad of painless swelling, sinus, and granular discharge. Diagnosis is made by biopsy and fungal culture. Fungal culture usually takes a minimum of 6–8 weeks.
Actinomycetoma and eumycetoma are two broad classifications of eumycetoma infections. The most common causes of actinomycetoma are Streptomyces somaliensis, Actinomadura pelletieri A19, Actinomadura madurae, Nocardia brasiliensis, and Nocardia asteroides. The most common cause of eumycetoma is Madurella mycetomatis, Magnaporthe grisea, Pseudallescheria boydii,and Leptosphaeria senegalensis.2
Actinomycetoma usually responds to antibiotic treatment and refractory cases may need debridement. Eumycetoma was usually refractory to antifungals and may need radical excision and soft tissue coverage.
A complete cure is very difficult to achieve and recurrence is most common. The recurrence rate varies from 20 to 50% and can be local or distant through the regional lymph nodes. This could be due to widespread disease along the fascial planes, inadequate excision, and lack of surgical experience, along with costly medications available for treatment which was not affordable by poor patients and lack of health education. Extensive involvement of limbs warrants amputation. Involvement of the dorsal part of the foot has a good prognosis compared to the plantar aspect.
CONCLUSION
There should be awareness about the existence and management of eumycetoma infection. Newer and cheaper antifungals needed to come into existence to make medical management feasible among all economic groups. Vast surgical experience is needed to debride the eumycetoma-infected areas as recurrence is very common. Adequate debridement with soft tissue cover with appropriate antifungals is needed to prevent a recurrence.
REFERENCES
1. Zijlstra EE, van de Sande WW, Welsh O, et al. Mycetoma: a unique neglected tropical disease. Lancet Infect Dis 2016;16(1):100–112. DOI: 10.1016/S1473-3099(15)00359-X
2. Verma P, Jha A. Mycetoma: reviewing a neglected disease. Clin Exp Dermatol 2019;44(2):123–129. DOI: 10.1111/ced.13642
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