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Mycetoma, madura foot
- 1. Topic (let us see after some clinical points) BY, DR. M. GOWRI SHANKAR, For suggestions mail me at shankarvaluable@gmail.com
- 2. • Some clinical findings • Topic proper • Interpretation of the same clinical findings and its treatment
- 3. • Before clinical finding let us see some basic microbiological aspects, • Gram stain stains bacteria and helps in differentiating G+ & G— • KOH mount lyses the tissue remnant in the pus and helps in the comparatively large fungal hyphae • GMS stains fungus and helps in identification of fungus
- 4. Patient 1 & 2 comes to surgery OPD with swelling, multiple sinuses & seropurulent with granules Patient 3 with swelling, multiple pus point & purulent discharge
- 5. Pus with granules taken and sent for, • Gram stain • KOH mount or GMS stain • Modified AFB Patient 1 with swelling, multiple sinuses & seropurulent with granules Patient 3 with swelling, multiple pus point & purulent discharge Patient 2 with swelling, multiple sinuses & seropurulent with granules Test Interpretation G/S + KOH (or) GMS -- Mod. AFB + Test Interpretation G/S -- KOH (or) GMS + Mod. AFB -- Test Interpretation G/S + KOH (or) GMS -- Mod. AFB --
- 6. Test Interpretation G/S + KOH (or) GMS -- Mod. AFB + Test Interpretation G/S -- KOH (or) GMS + Mod. AFB -- Test Interpretation G/S + KOH (or) GMS -- Mod. AFB -- So, this infection can be bacterial or fungal This infection is bacterial
- 7. Let us see the interpretation of the findings after a small discussion
- 8. Madura foot, Actinomycosis BY, DR. M. GOWRI SHANKAR,
- 9. Mycetoma / Madura foot (so, mycetoma can be fungal or bacterial)
- 10. Madura Foot Traumatic implantation of causative organisms Chronic Granulomatous Disease Madura foot is a triad of • Soft tissue swelling / tumour • Multiple sinus tracts • Characteristic macroscopic grains ( 4 to 6 wks )
- 11. History of Madura Foot • A disease with Swelling over foot Multiple sinus Granular discharge • Then carter in 1860 established its fungal (Mycotic) origin • So, the name Madura MyceToma / Madura foot came }was reported by GILL in1842 from Madurai, Tamil Nadu
- 12. Epidemiology of Madura Foot Epidemiology = analysis of distribution for evaluation of determinants • Time Endemic in tropic countries • Place Tropic countries Central & South Amer., Africa and India (TamilNadu) • Person Among the Farmers who walks with Bare foot
- 13. Causative Agents
- 14. Causative Factor • Causative factor can be • Bacteria • Fungus • If caused by bacteria (actinomycete group) termed as actinomycetoma • If caused by fungi (madurella, acremonium, exophiala) termed as eumycetoma Bacteria Fungi Eumycetoma ActinomycetomaMycetoma
- 15. Eumycetoma Actinomycetoma Causative agents Scedosporium, Madurella Mycetomatis, Aspergillus spp., Acremonium, Exophiala, e.t.c., Actinomycetes (family) (g+, filamentous) namely, a) Actinomadura b)Actinomyces c) Nocardia d)Streptomyces Causative Factor
- 17. • Typically present in agricultural workers (hands shoulders and back – from carrying contaminated vegetation and other burdens). Madura Foot Pathophysiology
- 18. • Individuals who walk barefoot in dry , dusty conditions Madura Foot Pathophysiology
- 19. In both the case there occurs traumatic implantation of the organisms occurs The granulomatous reaction starts And disease usually begins as small subcutaneous swelling over the involved region Which then enlarges burrowing the deeper tissues incl. bone And also the lesions tracks to the surface via multiple sinuses discharging vicid sereopurulent fluid with granules Madura Foot Pathophysiology Granules are nothing but the colony of microorganisms in the dense matrix of tissue
- 20. D/b Eumycetoma and Actinomycetoma Eumycetoma Actinomycetoma Scedosporium, Madurella Mycetomatis, Aspergillus spp., e.t.c., Actinomycetes namely, (g+, filamentous) a) Actinomadura b) Actinomyces c) Nocardia d) Streptomyces Above mentioned species may be PIGMENTED or NON PIGMENTED If pigmented the granules are colorfull (Brown) If non pigmented the granules are (white) These are G+, Bacilli, slender, Filamentous with branching (like fungus) Granules of all actinomycetes are (Yellow to White) except Actinomadura pelletieri For Actinomadura granules are Red colored Granules are nothing but the colony of microorganisms in the dense matrix of tissue. Colour of the granules = colony color of corresponding organism
- 21. D/b Eumycetoma and Actinomycetoma Eumycetoma Actinomycetoma Comparitively less no. of sinuses Low level of inflammation Serous / serosanguinous discharge Brown / White granules Multiple sinuses High level of inflammation Purulent discharge White granules Poor response to antimicrobials Although high level of inflammation, good response to Antimicrobials. So prolonged treatment needed
- 22. MCC of madura foot / mycetoma in world Actinomycetoma (60%) MCC of mycetoma in India Actinomycetoma (actinomadura madurae) MCC of Eumycetoma in India Madurella mycetomatis
- 23. • Slow spreading skin infection • Local swelling • Small hard painless nodules • Ulceration • Pus discharge • Scarred skin & discoloration • Itching • Pain and burning sensation Features of Mycetoma
- 24. Diagnosis
- 25. Madura Foot -- Diagnosis Granules are nothing but the colony of microorganisms in the dense matrix of tissue • Collect the pus with the granules • Wash the granules • Crush the granules b/w two slides • Then the crushed granules are used for various tests
- 26. 1. Microscopy a) Gram stain b) GMS stain for fungus or Simple KOH mount for 2 Steps for diagnosing and differentiating Mycetoma (with the crushed granules) If actinomycetoma, we will see G+ rods (bacilli), slender, filamentous, Branched organisms If Eumycetoma, we will see septate hyphae
- 27. 2. Culture • Actinomycetes grow on blood agar • Fungus ( Eumycetoma causing), grows in SDA agar – takes 2 wks for growth 3. Then with the organisms from the colony we can do (for proper identification) • Bio chemical reactions and • Immunofluorescence test 4. X- ray to evaluate the depth of the involvement 5. MRI and USG are also useful ( dot in circle sign ) 2 Steps for diagnosing and differentiating Mycetoma (with the crushed granules)
- 29. Treatment
- 30. Treatment of Mycetoma • For small lesions, • Antimicrobial theraphy • For deep or extensive cases, • Drainage / Excision of heavily invoved area / Debridement + • Antimicrobial theraphy • Incase of bony involvement, • Amputation + Antimicrobial theraphy For Actinomycotic lesions,,,
- 31. Antimicrobial theraphy for actinomycetoma includes., • First line drugs (any 2 used in combination) • Cotrimoxazole Or • Amikacin Or • Ceftriaxone Or • Imipenam • Second line drugs • Amoxyclav, rifampicin, sulphonamides, gentamycin Duration of course = 6 – 12 months after clinical cure Actinomycetoma shows excellent response to antimicrobial treatment
- 32. Treatment of EuMycetoma • 1st do surgery to reduce the fungal load • Then ketaconazole / itra / vori / posa conazoles For Eumycetomatic lesions,,, For Eumycetomatic lesions,,, Anti microbial treatment continued 6 – 12 months after clinical cure
- 33. Treatment of Mycetoma • For both the cases there is high chance for relapse (incase of severe Refractory or multiple relapse cases) • Amputation rate is 10 – 25 % ( since the swelling is painless the patient usually presents with later stages ) Amputation can be done
- 34. Diagnosis and Management of mycetoma
- 35. Patient 1 & 2 comes to surgery OPD with swelling, multiple sinuses & seropurulent with granules Patient 3 with swelling, multiple pus point & purulent discharge
- 36. Pus with granules taken and sent for, • Gram stain • KOH mount or GMS stain • Modified AFB Patient 1 with swelling, multiple sinuses & seropurulent with granules Patient 3 with swelling, multiple pus point & purulent discharge Patient 2 with swelling, multiple sinuses & seropurulent with granules Test Interpretation G/S + KOH (or) GMS -- Mod. AFB + Test Interpretation G/S -- KOH (or) GMS + Mod. AFB -- Test Interpretation G/S + KOH (or) GMS -- Mod. AFB --
- 37. Test Interpretation G/S + KOH (or) GMS -- Mod. AFB + Test Interpretation G/S -- KOH (or) GMS + Mod. AFB -- Test Interpretation G/S + KOH (or) GMS -- Mod. AFB -- So, this infection can be bacterial or fungal This infection is bacterial
- 38. Madura Foot with 1) Gram (+) 2) AFB (+) 3) Microscopically Branched Fungi like organism Actinomycetoma Madura Foot with 2) Gram (-) 2) AFB (-) 3) KOH mount showing filamentous hyphae Eumycetoma Madura Foot like swelling 3) Gram (+) 2) AFB (-) 3) Microscopically Gram-positive spherical cocci Botryomycosis
- 39. Thank You