5. Grains
• Vary in shape, size, texture and
color
• Actinomycotic grains : Soft and
brittle, off-white to pinkish
• Eumycotic : Firm, either black or
pale
6. M.mycetomatis
Black
Large (>5mm), Hard
Trematosphaeria grisea
Falciformispora seneglanesis
tompkinsii
Medicopsis romeroi
Exophiala jeanselmei
1-2 mm
Scedosporium boydii
Acremonium spp.
Fusarium spp.
Pale
1 mm
Actinomadura madurae Large (1-5 mm), Soft
Nocardia spp.
Small (<0.5mm), Soft
A.Pelletierii
Red Smaller (0.2 – 0.5 mm), hard
Streptomyces somaliensis
Yellow
Large round (0.5 – 2 mm),
hard
10. Direct microscopy
• Discharge is examined for grains
• Overnight Saline dressing if grains not observed
• Color, size and consistency are noted
• KOH and Gram stain is done by crushing the grains
• Calcofluor white can also be used
Gram staining
Filamentous
bacteria
Actinomycetoma
Acid fast positive
Nocardia
KOH mount
Septate hyphae
with /without
spores
Eumycetoma
11. Nocardia spp.: Partially acid fast
filamentous bacteria.
KOH wet mount direct microscopic
examination of M. mycetomatis grains
showing its hyphal structure.
12. HPE
• Epidermis : Normal/Hyperplastic/ulcerated
• Dermis : epithelioid cell granulomas with neutrophilic microabscess, with
grains in center.
• Stains used : Gram, ZN, PAS, GMS and Gridley
• Eumycetoma :
H&E : Large, dark brown/black/eosinophilic, with pale centres
PAS and GMS : Conidia or Chlamydospores on periphery and hyphae in center.
• Actinomycetoma : Large, irregular with darker basophilic periphery and pale
center.
13.
14.
15.
16. Culture
• Specimen is washed several times with NS and inoculated
• Medium used :
Modified Sabouraud dextrose agar supplemented with 0.5 % yeast
Brain-heart infusion agar
Lowenstein Jensen agar
• Eumycetoma require antibiotics contained media
Penicillin G, Streptomycin or chloramphenicol
Incubated for 4 – 6 weeks, at 25 and 37 degree Celsius.
17. FNAC
• Syringe under negative pressure in 3 different directions with short
stabs/corkscrew motion is inserted and aspirated.
• Used in early detection and epidemiological studies.
Serology
• Serum 1-3 beta-D-glucan was positive with Eumycetoma
18. Molecular methods
• MALDI-TOF MS : Matrix assisted Laser Desorption Ionization Time OF
Flight Mass Spectrometry
• Sequencing of the gene region “internal transcribed spacer” of rDNA
• Direct tissue identification of the organism : pan fungal PCR assay directly
on the sequencing regions, ITS1 and 2
• Mold identification : Multilocus DNA sequence analysis of
Large subunit (LSU)
Small subunit 18S nrDNA (SSU)
Β tubulin (TUB)
Chitin synthase 1 (CHS-1)
19. Imaging
• Involvement of joints and bones
• X ray findings : soft tissue swelling, bone sclerosis, bone cavities,
periosteal reaction, osteoporosis
• MRI and USG : ”Dot in circle sign”
20. • USG :
Eumycetoma : numerous, hyper-reflective echoes and there are
single or multiple thick-walled cavities with no acoustic enhancement
Actinomycetoma : echoes are closely aggregated and commonly seen
at the bottom of the cavities.
22. Early soft tissue swellings
• Phaeomycotic cysts : By HPE,
Never forms tissue granules
Composed of scattered individual
polymorphous fungal elements
Unorganised
Often intracellular
23. • Benign tumors-like fibromas and lipomas : Early lesions, By HPE
• Antibioma : antibiotic induced swelling, chronic sterile, tough fibrous
abscess,mostly single, treated by excision.
25. Lesions with discharging sinuses
Mycetoma
(Subcutaneous)
Exogenous (traumatic
inoculum)
Filamentous fungi or
aerobic actinomycetes
Actinomycosis
(Cervicofacial,
pulmonary, abdominal,
pelvic)
Endogenous (microbiota
of the digestive and
genital tract)
Anaerobic filamentous
bacteria
Botryomycosis
(Subcutaneous and
visceral)
Endogenous (microbiota
of the skin and digestive
tract)
Gram-positive cocci &
Gram- negative bacilli
26. Bone involvement
• Chronic bacterial osteomyelitis :
WBC : Marked leucocytosis as high as
20,000 or more.
The blood culture demonstrates the
presence of bacteraemia (taken during temp
spike).
Radiology: Lytic focus of bone destruction
surrounded by zone of sclerotic bone.
27. • Tuberculous osteomyelitis :
Adolescents, Blood borne
Extension from adjacent sites-ribs
Common sites- Spine- thoracic and lumbar,
Knees, Hips
Pott spine- erosion of the intervertebral discs
and involvement of multiple vertebrae, cold
abscess-psoas abscess.
HPE : Tubercular granuloma.
28. • Gummatous syphilis :
Relatively benign.
Usually develop 1-10 years after infection
and may involve any part.
single or multiple. Start as a superficial
nodule or as a deeper lesion that breaks
down to form punched-out ulcers.
Destructive but rapidly responds to
treatment, heals with scar.
30. Actinomycetoma
• Nocardia spp. : Cotrimoxazole or in combination with dapsone,
minocycline, or a combination of amikacin and imipenem.
• Actinomadura spp. and Streptomyces spp. : co-trimoxazole with
amikacin or dapsone or penicillin or streptomycin.
• Welsh regimen :
Cycles of amikacin 15 mg/kg IV along with cotrimoxazole for 21 days
with 15 days intervals when only cotrimoxazole is given (dose of oral
trimethoprim sulfamethoxazole 35 mg/kg/ day).
3 to 4 times, then cotrimoxazole as maintenance therapy
31. • Modified welsh regimen : To the Welsh regime, rifampicin 10
mg/kg/day is added
• Two-step regimen :
Intensive phase with penicillin, gentamycin and cotrimoxazole for 5–7
weeks
Amoxicillin and cotrimoxazole until 2–5 months after clinical cure
• Modified two-step regimen :
Intensive phase with gentamycin 80 mg IV twice daily and
cotrimoxazole 320/1600 mg orally twice daily for 4 weeks
maintenance phase of cotrimoxazole (same dosage) and doxycycline
100 mg twice daily and to be continued for 6 months after clinical
cure.
32. Eumycetoma
• often treated with a combination of antifungal therapy and surgery
• Itraconazole 200–400 mg/day is the treatment of choice.
• Other : Terbinafine 250–500 mg/day, Voriconazole 400 mg/day,
Posaconazole 200–800 mg/day.
33. Complications
• Disfigurement but is rarely fatal.
• Local abscess formation,
• Cellulitis, and
• Bacterial osteomyelitis.
• In advanced cases, deformities or ankylosis may occur.
