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Madura Foot
- 1. CASE MANAGEMENT Presentor: Dr.Shayne Calleja Moderator: Dr. Francia Balatan Resource Speakers: Dr. Joey Ranola Dr. Willbur Belleca MADURA FOOT
- 2. GENERAL OBJECTIVE • Topresent a case of a rare chronic foot infection.
- 3. SPECIFIC OBJECTIVES • Todiscuss the clinical presentation of Madura foot that differentiates it from other foot infections • To show the characteristic radiological findings as well as macroscopic and microscopic presentation of Madura foot • To present the diagnostic and treatment approach in patients with Madura foot • To discuss the role of surgical intervention in the management of Madura foot
- 4. GENERAL DATA • CW.V., •37/M, • Filipino, single, • Roman Catholic, • presently residing at St. Paul Subdivision, Palestina, Pili, Camarines Sur, • Admitted on November 28, 2012
- 5. CHIEF COMPLAINT: • Infectedwound, left foot
- 6. HISTORY OF PRESENTILLNESS • 36 MONTHS PTA • (+) insect bite at the dorsum of his left foot swollen • Consultation was done and he was given several antibiotics. • advised wound debridement financial constraints opted for medical management and took different antibiotics x 1 year swelling subsided
- 7. HISTORY OF PRESENTILLNESS • 12 months PTA, • left foot swelling recurred. • Consulted an herbolaryo herbal medicines including banaba leaves, malunggay leaves, guava leaves and tubo temporarily relieved • consulted a private MD Ciprofloxacin, Naproxen Na and Omeprazole
- 8. HISTORY OF PRESENTILLNESS • 9 months PTA, • (+) swelling of his left foot with intermittent discharge of pus, • consulted an Infectious Disease specialist anti-koch’s meds started jaundice anti- Koch’s discontinued given Godex, anti-kochs resumed in separate tablets Liver function tests: normal
- 9. HISTORY OF PRESENTILLNESS • 4 months PTA, • (+) painless subcutaneous nodules and sinus tracts with yellowish exudates • sought second opinion with an orthopedic surgeon • CT scan of the left foot: osteomyelitis • Advised I and D and possible amputation refused surgical management • returned to the ID specialist: anti-koch’s medications continued
- 10. HISTORY OF PRESENTILLNESS • 1 month PTA • (+) painless subcutaneous nodules and sinus tracts with yellowish exudates • Cloxacillin sodium was added to his anti- koch’s regimen.
- 11. HISTORY OF PRESENTILLNESS • 1 week PTA, • several subcutaneous nodules erupting with sinus tracts containing yellowish exudates • (+) Pain and swelling took Ibuprofen and Mefenamic acid • (+) difficulty in ambulation • (+) fever relieved by paracetamol • Wound dressing with Terramycin ointment.
- 12. HISTORY OF PRESENTILLNESS • Few hours PTA, • (+) pain, swelling and eruption of several subcutaneous nodules with sinus tracts ADMITTED
- 13. PAST MEDICAL HISTORY: •(-) Hypertension, • (-) Diabetes Mellitus, • (-) PTB, • (-) Bronchial Asthma • (-) History of travel to endemic places
- 14. PERSONAL/SOCIAL HISTORY: • Patientis a veterinarian. • A non-smoker, non-alcoholic beverage drinker.
- 15.
- 16. ROS: (-) Weight Loss(-) Anorexia (-) Cough/colds (-) Dyspnea (-) Easy Fatigability (-) chest pain (-) Orthopnea (-) Changes in bowel habits (-) melena (-) hematochezia (-) polyuria (-) polydypsia (-) polyphagia (-) limitation of movement
- 17. PHYSICAL EXAMINATION Patient isconscious, coherent, not in cardiorespiratory distress BP: 90/60 PR: 60 RR: 19 T: 36.3 Pale palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no nasoaural discharge, no palpable cervicolymphadenopathy, (+) inguinal lymphadenpathy Symmetrical chest expansion, no retraction, no crackles, no wheezes Adynamic precordium, normal rate, regular rhythm, good S1 and S2, apex beat at 5th ICS LMCL, no murmur
- 18. PHYSICAL EXAMINATION Abdomen isflabby, normoactive bowel sounds, (+) direct tenderness on hypogastric area, (+) CVA tenderness, bilateral; no organomegaly, no guarding Swelling of the left foot, with hyperpigmentation and formation of abscess and sinus tracts with yellowish discharge/granules embedded in a shell-like substance.
- 19. DORSUM OF LEFTFOOT
- 20. DORSUM OF LEFTFOOT
- 21. PLANTAR ASPECT OFLEFT FOOT
- 22. PHYSICAL EXAMINATION Neuro Exam: Patientis oriented to time, place and person. I – Can smell coffee II, III – Pupils equally reactive to light III, IV, VI – Extraocular movements intact V - Corneal Reflex intact VII Can raise eyebrows, smile, close both eyes tightly, puff out both cheeks VIII Can Hear IX, X (+) Gag Reflex XI Can shrug shoulder XII Tongue midline, good articulation Motor: Good muscle bulk and tone. Strength is 5/5 throughout. Cerebellar: No pronator drift. Gait with normal base Sensory: Pinprick, light touch, position and vibration sense intact Reflexes: 2+
- 23. ADMITTING IMPRESSION: • ChronicInflammation, L foot; • Osteomyelitis; • T/C Madura Foot
- 24. DIFFERENTIAL DIAGNOSIS: • ChronicBacterial Osteomyelitis • Cutaneous Tuberculosis • Neoplasm
- 25. COURSE IN THEWARD 11/28/2012 Blood Urea Nitrogen 5.0 Sodium 140 Potassium 3.3 Creatinine 97.4 Reticulocyte count 0.55 CBC Wbc Hemoglobin Hematocrit Platelet Neutrophil Lymphocyte Monocyte 11.69 7.6 23.4 314 78 16.2 5.2
- 26. Left Foot AP-O Thereis sclerosis of the visualized metatarsals and 1st proximal phalanx with small areas of lucencies. This may suggest osteomyelitis. There is soft tissue swelling and multiple soft tissue nodularities.
- 27. LEFT FOOT AP SCLEROSISWITH AREAS OF LUCENCIES SOFT TISSUE NODULARITIES SOFT TISSUE SWELLING
- 28. COURSE IN THEWARD • Oxacillin 1g TIV q4 • Shifted to: Ampicillin 1g IV q8 + Gentamycin 7mg/kg/day • Levofloxacin 750mg tab OD was added
- 29. Debridement and curettagewas done.
- 30. TREATMENT • GSCS ofwound: no growth after 5 days of incubation • Tissue biopsy: revealed fibroconnective tissue containing numerous grayish-blue granules surrounded by abscess. Histopathologic diagnosis consistent with mycetoma.
- 31. TREATMENT: • Trimethroprim-Sulfamethoxazole 800/160mg/tabBID x 3 months • Streptomycin (14mg/kg/day) 700mg IM OD x 1 month, then 3x/week for the next 2 months
- 32. After 1 weekof treatment…
- 33. ON FOLLOW UP… •At the OPD… • (+) hypersensitivity to trimethoprim- sulfamethoxazole dose was adjusted and eventually discontinued.
- 34.
- 35.
- 36. On follow up… •The patient has been followed up for the next four weeks without evidence of recurrence.
- 37.
- 38. On follow up…4 weeks after initiation of treatment.
- 39.
- 40. MYCETOMA • A chronicprogressive granulomatous infection of the skin and subcutaneous tissue • most often affecting the lower extremities typically a single foot • TRIAD OF SYMPTOMS: • localized swelling, • underlying sinus tracts, • production of grains or granules (comprised of aggregations of the causative organism) within the sinus tracts Mandell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 41. MADURA FOOT FUNGI •EUMYCETOMA BACTERIA • ACTINOMYCETOMA MYCETOMA Mandell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 42. EPIDEMIOLOGY • Most commonlyfound in tropical and subtropical climates, • One of the largest current group of cases is in Sudan • 5:1 male to female ratio • 20-40 year old age range • More common in agricultural workers and outdoor laborers • M. mycetomatis: Most common cause • Drier regions: A. madurae, M. mycetomatis, S. somaliensis • Wet regions: P. boydii, Nocardia, A. pelletieri Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 43. CLINICAL MANIFESTATIONS • 75%:lower extremities foot (70%) single, small lesion, painless subcutaneous nodule increases in size becomes fixed to the underlying tissue sinus tracts formation open to surface drain purulent material with grains Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 44. • Overlying skinappears smooth and shiny • Skin may be hyper or hypopigmented • Swelling is firm and nontender • Extensive local damage may lead to muscle wasting, bone destruction and limb deformities • No signs or symptoms of systemic illness. Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 45. DIAGNOSIS: CLASSIC TRIAD Painless soft tissue swelling Drainingsinus tracts Extrusion of grains
- 46. DIAGNOSIS • Deep biopsywith histopathology and culture is usually not necessary, although deep tissue biopsy avoids the bacterial contamination of surface cultures. • Alternative strategy: aspiration of grains directly from an unopened sinus tract for microscopic observation and culture to diagnose the specific cause of mycetoma Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 47. MICROSCOPIC DIFFERENTIATION BETWEEN ACTINOMYCETOMAvs EUMYCETOMA • Actinomycetes have granules of about 100 µm in diameter, with delicate, branched filaments measuring about 1 µm in diameter. • fungal grains are observed as a mass of hyphae embedded in intercellular cement, and the filaments are wider than 1 µm. Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 48. DIAGNOSIS: ROLE OFRADIOLOGY • Important in: assessment of disease extent, bone involvement, and long term follow up of disease regression and or progression. • ULTRASONOGRAPHY: • EUMYCETOMA : produce single or multiple thick- walled cavities, without acoustic enhancement, with grains represented as distinct hyperreflective echoes • ACTINOMYCETOMA: grains produced fine echoes that were found at the bottom of the cavities Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 49. DIAGNOSIS: • MAGNETIC RESONANCE IMAGING • “dot-in-circle”sign • CT SCAN • Sensitive for detecting early changes consistent with bone involvement Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 50. TREATMENT: ROLE OFSURGERY • In eumycetoma, if the patient's disease has not responded to antifungal medical treatment wide local and debulking excisions and even amputation • In actinomycetoma: amputation is infrequently indicated Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 51. TREATMENT: ACTINOMYCETOMA • streptomycin(14 mg/kg/day IM) is given for the first month (and sometimes three times weekly thereafter for several months) in addition to a long course of TMP- SMX, usually one double-strength tablet (160 mg trimethoprim and 800 mg sulfamethoxazole) twice daily, or dapsone (1.5 mg/kg/day twice daily) • Alternate regimens: • TMP-SMX + dapsone • amikacin +TMP-SMX. Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 52. TREATMENT: EUMYCETOMA • Itraconazole(400 mg/day) or ketoconazole (200 to 400 mg/day) are considered first- line azole agents in the treatment of this disease • Successful therapy with terbinafine, an allylamine antifungal, has also been reported Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.
- 53. THANK YOU! Mendell, Douglas,and Bennett's Principles and Practice of