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  1. 1. MYCETOMADr.T.V.Rao MDDr.T.V.Rao MD 1
  2. 2. What is Mycetoma• Mycetoma is a chronic granulomatous,progressive inflammatory disease thatinvolves the subcutaneous tissue after atraumatic inoculation of the causativeorganism. It may be caused by true fungi(eumycetes) or by higher bacteria(actinomycetes) and therefore it is classifiedinto eumycetoma and actinomycetomarespectively.Dr.T.V.Rao MD 2
  3. 3. Mycetoma• Mycetoma is a chronic subcutaneousinfection caused by actinomycetes orfungi. This infection results in agranulomatous inflammatoryresponse in the deep dermis andsubcutaneous tissue, which canextend to the underlying bone.Dr.T.V.Rao MD 3
  4. 4. Mycetoma• Mycetoma is characterized by theformation of grains containing aggregatesof the causative organisms that may bedischarged onto the skin surface throughmultiple sinuses. Mycetoma was firstdescribed in the mid 1800s and initiallynamed Madura foot, after the region ofMadura in India where the disease wasfirst identified. Dr.T.V.Rao MD 4
  5. 5. Mycetoma• Mycetoma caused byMicroaerophilicactinomycetes istermedactinomycetoma,and mycetomacaused by true fungiis calledeumycetoma.Dr.T.V.Rao MD 5
  6. 6. Presentation of Mycetoma• The characteristic triad of a painlesssubcutaneous mass, sinuses and the dischargeof grains is pathognomic of mycetoma. Thelesion usually presents as a slowly progressivepainless swelling at the site of previoustrauma and gradually increases in size. It mayspread to involve the skin and deep structuresresulting in destruction of bone, deformityand loss of function with serious social andeconomic implications.Dr.T.V.Rao MD 6
  7. 7. Madura foot• Madura foot is a chronic granulomatousinfection of the bones and soft tissues of thefoot resulting in mycetoma formation andgross deformity. It occurs in Sudan, NorthAfrica and the west coast of India, principallyamong those who walk barefoot and aretherefore prone to contamination of footinjuries by soil-derived organisms.Dr.T.V.Rao MD 7
  8. 8. Madura foot• A common causativeorganism isActinomadura madurae,but Madura foot is alsocaused by otheractinomycetes includingStreptomycessomaliensis and byfungiDr.T.V.Rao MD 8
  9. 9. Aetiological Agents of Mycetoma• More than 20species of fungi andbacteria can causemycetoma. The ratioof mycetoma casescaused by bacteria(actinomycetoma) tothose caused by truefungi (eumycetoma)Dr.T.V.Rao MD 9
  10. 10. Actinomadura sppDr.T.V.Rao MD 10
  11. 11. Mycetoma• The body parts affected mostcommonly in persons withmycetoma include the foot or lowerleg, with infection of the dorsalaspect of the forefoot being typical.The hand is the next most commonlocation; however, mycetoma lesionscan occur anywhere on the body.Dr.T.V.Rao MD 11
  12. 12. Mycetoma Lesions• Lesions on the chestand back arefrequently caused byNocardia species,whereas lesions onthe head and neckare usually causedby Streptomycessomaliensis.Dr.T.V.Rao MD 12
  13. 13. Pathogenesis• The causative organism enters through sites oflocal trauma (eg, cut on the hand, footsplinter, local trauma related to carrying soil-contaminated material). A neutrophilicresponse initially occurs, which may befollowed by a granulomatous reaction. Spreadoccurs through skin facial planes and caninvolve the bone. Haematogenous orlymphatic spread is uncommon.Dr.T.V.Rao MD 13
  14. 14. Actinomycetoma can be caused by thefollowing:• Actinomaduramadurae• Actinomadurapelletieri• Streptomycessomaliensis• Nocardia speciesDr.T.V.Rao MD 14
  15. 15. Clinical Presentations of MycetomaDr.T.V.Rao MD 15
  16. 16. Clinical Presentations of MycetomaDr.T.V.Rao MD 16
  17. 17. Eumycetoma• Eumycetoma ismainly causedby P boydii (Sapiospermum)or Madurellamycetomatis.Dr.T.V.Rao MD 17
  18. 18. Botryomycosis• Botryomycosis is a chronic, Suppurativeinfection characterized by a granulomatousinflammatory response to bacterialpathogens; it may present with cutaneous or,less commonly, visceral involvement . Theterm botryomycosis is derived from the Greekword botrys (meaning "bunch of grapes") andmycosis (a misnomer, due to the presumedfungal etiology in early descriptions).Dr.T.V.Rao MD 18
  19. 19. Botryomycosis• Other terms used todescribebotryomycosisinclude bacterialpseudomycosis,staphylococcalactinophytosis,granular bacteriosis,and actinobacillosisDr.T.V.Rao MD 19
  20. 20. Fine needle Aspiration Cytology ofMycetoma:• Mycetoma can beaccurately diagnosed byFine Needle Aspiration(FNA) cytology. Mycetomalesion has a distinctappearance in a cytologysmear characterised by thepresence of polymorphousinflammatory cellsconsisting of an admixtureof neutrophils,lymphocytes, plasma cells,Dr.T.V.Rao MD 20
  21. 21. Identification of pathogens• The mycetoma causative organisms can beidentified by their textural description,morphological and biological activities in pureculture. The biological activity may includeacid fastness, optimal temperature,proteolytic activity, utilization of sugars andnitrogenous compounds. The grains are thesource of the culture and they should be aliveand free of contaminants and they are usuallyobtained by deep surgical biopsy.Dr.T.V.Rao MD 21
  22. 22. Treatment of Mycetoma• The treatment of mycetoma dependsmainly on its aetiological agent andthe extent of the disease. Untilrecently, in many centres, the onlyavailable treatment for mycetomawas amputation or mutilatingsurgical excision of the affected partDr.T.V.Rao MD 22
  23. 23. Treatment of Mycetoma• Actinomycetoma is amenable to medicaltreatment with antibiotics and otherchemotherapeutic agents. Combined drugtherapy is always preferred to a single drug toavoid drug resistance and to eradicate residualinfection.• The common drugs regimes are:• 1- Amikacin sulphate (15 mg/kg) in combinationwith Co-trimoxazole(14 mg/kg twice daily) is thefirst line for actinomycetoma treatment.•Dr.T.V.Rao MD 23
  24. 24. Surgical Treatment• Surgical excision is recommended for smalllocalized lesions, debulking of massive lesions;for better response to medical treatment andfor lesions became well encapsulated bymedical treatment.• Amputation rarely done nowadays. It is donefor very advanced lesions with bad generalcondition and as a life saving procedure.Dr.T.V.Rao MD 24
  25. 25. For More Articles of Interest onInfectious Diseases Visit Me …Rao,s Infection care on FACEBOOK 255/21/2013
  26. 26. • Programme Created by Dr.T.V.Rao MDfor Medical and Paramedical Students• Email• doctortvrao@gmail.comDr.T.V.Rao MD 26