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Mycetoma
- 1. SUBCUTANEOUS MYCOSES (MYCETOMA) Ankur Vashishtha AssistantProfessor IIMT University, Meerut
- 2. SUBCUTANEOUS MYCOSES • Theagents of subcutaneous mycoses usually inhabit the soil. They enter the skin by traumatic inoculation with contaminated material and tend to produce the granulomatous lesions in the subcutaneous tissue.
- 3. MYCETOMA • Mycetoma isa chronic, slowly progressive granulomatous infection of the skin and subcutaneous tissues. • Clinically, it is manifested as a triad of swelling, discharging sinuses and presence of granules in the discharge • Mycetoma is also known as Maduramycosis or Madura foot, as it was first described in Madurai, South India, by John Gill (1842).
- 4. Types of Mycetomaand Causative Agents • Mycetoma can be of two types. It can be caused by either fungal agents (eumycetoma) or bacterial agents (actinomycetoma). 1. Eumycetoma 2. Actinomycetoma
- 5. Agents of Mycetomaand types of grains they produce Eumycetoma (Fungal agent) Actinomycetoma (Bacterial agent) 1. Black granules • Madurella mycetomatis • Madurella grisea • Exophiala jeanselmei • Curvularia species 1. White to yellow Granules • Nocardia species • Streptomyces somaliensis • Antinomadura madural 2. White Granules • Pseuallesceria bydii • Aspergillus nidulans • Acremonium species • Fusarium sopecies 2. Pink to red Geanules • Actinomadura pelletieri
- 7. Pathogenesis • The causativeagents enter the skin or subcutaneous tissue from the contaminated soil, usually by the accidental trauma such as thorn prick or splinter injury.
- 8. Clinical Manifestations Hallmark ofmycetoma is presence of clinical triad consisting of:- • Tumor like swelling, i.e. tumefaction • Discharging sinuses • Discharge oozing from sinuses containing granules.
- 9. Epidemiology Mycetoma is endemicin Africa, India, the Central and South America, and has a non-uniform distribution. • Overall, actinomycetoma is more common ( 60%) than eumycetoma (40%) globally, whereas eumycetoma is more common in Africa However, within a country,
- 10. Laboratory Diagnosis Specimen Collection •The lesions should be cleaned with antiseptics and the grains should be collected on sterile gauze by pressing the sinuses from periphery or by using a loop.
- 11. DirectExamination • Granules arethoroughly washed in sterile saline; crushed between the slides and examined. • Macroscopic appearance of granules such as color, size, shape, texture may provide important clue to identify the etiological agent
- 12. • If eumycetomais suspected: Grains are subjected to KOH mount, which reveals hyphae of2- 6 μm width along with chlamydospores at margin • If actinomycetoma is suspected: Grains are subjected to Gram staining which reveals filamentous grampositive bacilli (0.5-1 μm wide). Modified acid fast stain is performed if Nocardia is suspected, as it is partially acid fast
- 14. Histopathological staining • H& E Satin • PAS • GMS
- 15. Culture • For fungalSDA and Bacteriological such Lowenstein Jensen media. • For fungal:- Inoculated on SDA with antibiotics like chloramphenicol and gentamicin, and incubated at 25°C, 37°C and 44°C. • For bacterial:- Inoculate on Blood agar, LJ and SDA tubes.
- 16. IDENTIFICATION For Eumycetoma (Fungalagent) For Actinomycetoma (Bacterial agent) Observation of the growth rate Growth rate Colony Morphology Colony Morphology Production of Candida Urease test Sugar assimilation patterns Tyrosine test
- 17. Treatment • Treatment ofmycetoma consists of surgical removal of the lesion followed by use of: • Antifungal agents for eumycetoma (Itraconazole or amphotericin B for 8- 24 months). • Antibiotics for actinomycetoma such as (amikacin plus cotrimoxazole).
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