Molecular identification of Actinomadura madurae isolated from a patient originally from Algeria; observations from a case report.

BACKGROUND: Mycetoma is a chronic granulomatous subcutaneous infection caused by anaerobic pseudofilamentous bacteria or fungi. It is commonly prevalent in tropical and subtropical countries. Men are more susceptible to the disease due to greater participation in agricultural works. Mycetoma commonly involves lower extremities, wherein untreated cases lead to aggressive therapeutic choices, such as amputation of the affected body organs and consequently lifelong disability. CASE PRESENTATION: In this report, we present the rare case of a 58-year-old man, originally from Algeria with a left foot chronic tumefaction of 5 years. In the initial clinical examination, mycetoma was diagnosed based on tumefaction and the presence of multiple sinuses with the emission of white grains. The latter was observed via direct examination. The histopathological analysis demonstrated an actinomycetoma caused by bacteria, as the etiological agent. Imaging showed a bone involvement with osteolysis at the levels of 2nd to 4th metatarsal diaphysis. The mycological and bacterial cultures were both negative. For an accurate diagnosis, the obtained grains were subjected to molecular analysis, targeting the 16S-rDNA gene. Molecular identification yielded Actinomadura madurae as the causal agent, and 800/160 mg of trimethoprim/sulfamethoxazole was prescribed twice a day for 1 year, as a treatment. CONCLUSION: Considering low information about this disease, especially in non-endemic areas, it is of high importance to enhance the knowledge and awareness of clinicians and healthcare providers, in particular in the countries with immigration issues.

[Eumycetoma due to Fusarium chlamydosporum : Case report und review of the literature]. / Eumyzetom durch Fusarium chlamydosporum : Fallbericht und Literaturübersicht.

Eumycetomas are chronic purulent infections by (mold) fungi that affect the skin and subcutaneous tissue and are associated with a granulomatous inflammatory reaction. An affection of deeper structures is possible and can lead to amputation. In most cases, the distal lower limbs are affected. The clinically similar actinomycetoma is caused by gram-positive, filamentous bacteria. Both diseases are subsumed as mycetomas and have been classified by the World Health Organization as "neglected tropical diseases". Eumycetomas are endemic in the "Trans-African Belt". Pathophysiologically, there is an inoculation of the respective, partially ubiquitous pathogens into the skin through microtrauma during barefoot walking. Characteristic criteria in histology are grains which correspond to microcolonies of the pathogen in vivo. In addition to culturing the pathogen, further molecular diagnostics should be pursued. Imaging procedures are usually necessary before major surgery. The treatment is difficult and lengthy and the use of systemic antifungals in combination with an operative approach is the first-line treatment. Itraconazole continues to be the gold standard. In refractory cases terbinafine can be used as a second-line therapy. Wearing sturdy footwear is an effective prophylaxis. Although preventable and treatable, eumycetoma, as a disease of the poor, remains endemic and is associated with considerable morbidity and socioeconomic burden. This is the first report on a eumycetoma in a patient from Sudan due to Fusarium chlamydosporum. Treatment with oral terbinafine for 1.5 years was successful.

Madura foot caused by Gordonia terrae misdiagnosed as Nocardia.

Actinomycetomas are soft tissue bacterial infections that are in the differential for unusual masses of the extremities. Typical infectious agents include Actinomyces and Nocardia and are treated with long-term antibiotics. We report a rare case of Gordonia actinomycetoma that was misdiagnosed as Nocardia and subsequently required surgical excision in addition to antibiotic therapy.

Eumicetoma: actualidades y perspectivas.

The eumycetoma is a severely debilitating chronic progressive fungal cutaneous infection. Classic clinical triad is characterized by painless subcutaneous mass, sinus tracts formation and sero-purulent discharge that contain aggregates of fungal hyphae called grains. Any part of the body can have affected, with extension to muscular or bone, even visceral compromised. The eumycetoma is observed in tropical and subtropical countries; In Latin-America, is reported with less frequency. In endemic areas, antibody presence again etiological agents were higher compared with number of people affected, thus it is supposed that individual genetic susceptibility most by exist. Recently, it was reported specific polymorphism in genes CR1, IL-8, NOS2 and chitriosidase, which were associated with development of eumycetoma. The diagnosis is suggested by clinical presentation; the histopathology and microbiology studies, plus radiologic valuation confirmed diagnosis. Madurella mycetomatis is the most informed etiological agent. Using phylogenetic tools new species in genus Madurella were reported; moreover, Trematosphaeria grisea and Pseudallescheria boydii were reclassified. Etiological agent Identification is important, because differences in antifungal susceptibility exist. Eumycetoma treatment includes surgery plus antifungal drugs. Identification of etiological agents is primordial, because antifungal resistance could exist. To development new pharmacological strategies, comprehension of grain formation physiology and drugs effects are necessary.

Madura foot in Europe: diagnosis of an autochthonous case by molecular approach and review of the literature.

Madura foot is a chronic granulomatous infection of the soft-tissue of the foot and it is endemic in tropical and subtropical countries. Some cases have also been reported in local people or migrants in temperate countries. The microbiological diagnosis requires prolonged bacterial cultures in aerobic and anaerobic conditions, but the use of the molecular approach could be helpful for an early and rapid diagnosis. We describe an autochthonous case of Actinomadura madurae foot infection in an Italian woman. The diagnosis was achieved 36 months after symptoms onset by PCR detection and sequencing of 16S rDNA directly on biopsy. She started therapy with rifampin, trimethoprim-sulfamethoxazole, and amikacin. After 3 months the pain had disappeared and the swelling subsided. We reviewed the literature on Madura foot due to bacterial causative agents in Europe and observed that the median time from onset to diagnosis is high, possibly due to several factors like the difficulties of the microbiological and radiological diagnosis. Our case report and the review of literature point out that the implementation of a surveillance system, the involvement of an infectious diseases specialist, with experience in tropical diseases, and the availability of a microbiology unit to perform feasible and rapid molecular diagnostic tests could result in an earlier diagnosis and an optimal antibiotic therapy of this rare but difficult-to-treat and, above all, difficult-to-diagnose infection.

Pseudotumoral presentation of fungating mycetoma caused by Phaeoacremonium fuscum in a renal transplant patient.

Eumycetoma is an unusual infection in immunocompromised patients outside the tropics, caused by a variety of fungal pathogens. We describe the case of a 51-year-old renal transplant recipient who presented with a large pseudotumoral foot lesion necessitating complete surgical excision of the lesion. Cultures and molecular diagnosis confirmed Phaeoacremonium fuscum. This is the first case, to our knowledge, of fungating mycetoma caused by this fungal species in a solid organ transplant recipient.

[Mycetoma of the foot: a case report]. / Mycétome actino-mycosique du pied, à propos d'un cas.

Mycetoma is a chronic inflammatory cutaneous and subcutaneous pathology caused by either a fongic (eumycetoma) or bacterial (actinomycetoma) infection, which lead to a granulomatous tumefaction with multiple sinuses. When localized in the foot this infection is named "Madura foot". This infection is endemic to tropical and subtropical regions and rarely occurs in western countries. A historical case in Europe of a foot mycetoma evolving since 20 years without any treatment is presented. A histopathologic diagnosis of actinomycetoma has been done in 1987. The patient presented a severe Staphylococcus aureus chronic osteitis leading to a trans-tibial amputation. This case allows to present this infection which, even if rarely presented in France, can be meet especially among a migrant's population.

A Novel Report of mycetoma with Spinal Spread due to Madurella fahalli from India.

Eumycetoma caused by Madurella fahalii, a drug-resistant fungus, has never been reported in India. Here, we describe a fatal case of eumycetoma with spinal involvement due to M. fahalii for the first time in India.

Early presentation of mycetoma (Madura Foot): A case report.

Mycetoma, commonly known as Madura foot, is a chronic and progressively destructive granulomatous disease caused by a fungus or anaerobic filamentous bacteria that affects the skin, subcutaneous tissue, and bones primarily in tropical and subtropical regions, with males between the ages of 20-40 having occupational exposure to outdoor environments, such as farming, predominantly affected. It is one of the World Health Organization's 17 "neglected tropical diseases," characterized by a clinical trial of localized mass-like soft tissue injury with draining sinuses that discharge grains of infectious material. Here, we present a case report of a 40-year-old male with type 2 diabetes mellitus and a history of fieldwork, who exhibited early manifestations of mycetoma. Unlike the typical diffuse presentation seen in advanced cases, this patient's early presentation prompted diagnostic challenges due to its atypical nature. We highlight the importance of recognizing the early signs of mycetoma, particularly in individuals with predisposing factors such as diabetes and occupational exposure. Diagnostic dilemmas may arise, leading to potential misdiagnosis. Additionally, we emphasize the crucial role of biopsy in confirming the diagnosis, alongside imaging techniques, to facilitate timely intervention and management, thereby significantly impacting patient outcomes.

Importance of clinico-pathologic correlation in rare, chronic infectious diseases: Actinomycetoma misdiagnosed as botryomycosis-A case report.

This case report explores the clinical journey of a patient initially diagnosed with botryomycosis, only to later reveal the underlying and rare condition of actinomycosis. The report highlights the challenges in getting to an accurate diagnosis, emphasizing the importance of considering uncommon pathologies, the utility of multi-disciplinary teams and clinico-pathologic correlation in clinical practice.

Chronic Painless, Multiple Papulo-Nodular Skin Lesion at Foot Resembles Mycetoma Infection (Madura Foot): A Case Report.

Madura foot is a chronic, progressively destructive bacterial or fungal infection of the subcutaneous tissues, which may affect skin, muscle, and bone. It is endemic in tropical and subtropical areas known as the "Mycetoma belt" between latitude 30°N and 15°S. Mycetoma is prevalent in the poor population living in remote areas of developing countries that lack proper reporting system and management. The World Health Organization recognized mycetoma as a neglected tropical disease back in 2016. Though the diagnosis is challenging, early detection and proper treatment can reduce morbidity and provide a promising outcome. We report a case of chronic painless, multiple papulo-nodular skin lesions at the foot that resembles mycetoma infection which was detected early and recovered with a satisfactory outcome with proper treatment.

Case report: The dot in circle sign: A pathognomonic MRI sign of Madura foot.

Mycetoma or Madura's foot is a rare condition in Morocco. It is a chronic infection that affects deep subcutaneous tissues and may eventually spread to deep tissues, muscles, and bones. It is caused by fungi or bacteria and most often affects the foot. Biopsy and microbiological examination help to establish a definitive diagnosis, but may delay it. Imaging plays a crucial role in early diagnosis, particularly MRI findings that show a pathognomonic sign of mycetoma which is the dot-in-the-circle sign. Computed tomography provides a better analysis of bone changes than plain radiography. Treatment is very difficult, especially if the diagnosis is delayed, and may even lead to amputation. We present here a case of mycetoma of the foot with some MRI features.

Primary Cutaneous Actinomycosis: A Diagnostic Enigma.

Actinomyces are Gram-positive, filamentous rods found endogenously as a part of the normal flora and can be acquired exogenously as they are present in the soil. The most common species known to infect humans is Actinomyces israelii. Five forms of the disease have been identified so far, of which the primary infection of the skin is the most uncommon. It is also commonly considered one of the most misdiagnosed diseases. We present a case of a young male diagnosed with primary cutaneous actinomycosis based on a histopathology specimen after multiple failed diagnoses of Madura foot/mycetoma, cutaneous tuberculosis, and malignancy. The patient was successfully treated with antibiotics with the restoration of his functional disability caused by the lesion.

Madura foot and a continued diagnostic enigma: Dot-in-circle sign on magnetic resonance imaging and ultrasound.

Madura foot is a chronic granulomatous disease of the skin and underlying tissues caused by fungi or bacteria. Early diagnosis is important to avoid disfiguring limb deformities. Low clinical suspicion, limited availability of diagnostic tools, and infection with fastidious organisms may lead to misdiagnosis and delayed treatment. Imaging tests can help to make a timely diagnosis in a non-invasive manner. Here we report two patients with a non-classical clinical presentation and a more favorable differential diagnoses who were correctly diagnosed as cases of Madura foot based on the ''dot-in-circle sign'', a specific finding on magnetic resonance imaging and ultrasound.

Histopathological Diagnosis of Eumycetoma With Paraspinal Sinuses: A Rare Case Report.

Mycetoma, well known as "Madura foot," is a long-standing granulomatous infection of the skin and subcutaneous tissue. Causative organisms are filamentous fungi (eumycetes) and bacteria (actinomycetes). It characteristically presents with firm woody swelling, discharging sinuses with grains (containing the causative organism). Diagnosis in suspected cases can be made by microbiological evaluation, histopathological, cytological and radio imaging techniques. To differentiate between eumycetoma and actinomycetes histopathology is an accurate diagnostic modality as seen in the present case. We report a case of 42 years male who presented with swelling on his back with discharging sinus. Histopathological specimen containing multiple, irregular, greyish, whitish tissue pieces with skin attached all together measuring around 12×9×4 cm from the paraspinal region. The section shows histopathological features suggestive of eumycetoma. Periodic acid -Schiff stain showed the presence of septate, branching fungal hyphae and black granules. Eumycetoma can be accurately diagnosed by histopathological evaluation using a special stain. It is confirmatory and provides a guide for treatment plans with a high index of suspicion.

Clinical Features of Mycetoma and the Appropriate Treatment Options.

Mycetoma is a chronic, suppurative and debilitating granulomatous infection seen mainly in tropical and subtropical areas and is now declared as a neglected tropical disease by the World Health Organization. The clinical diagnosis is usually characterized by a classical triad of localized swelling, underlying sinus tracts, and production of grains or granules, but unusual presentations are also seen. It is classified into eumycetoma caused by the fungus, and actinomycetoma caused by the bacteria. The clinical presentation of both is almost similar and a definite diagnosis is essential before starting the treatment as it differs for both. Surgical debulking followed by a prolonged course of medical therapy now forms the mainstay of treatment due to the long course of the disease and suboptimal response. This review focuses on the various usual as well as unusual clinical presentations of mycetoma, established treatment regimens as well as recent changes in the mode of administration of drugs and newer drugs for mycetoma.

An Illustrative Report of Three Cases of Madura Foot with Diagnostic and Treatment Features.

Introduction: Madura foot is a rare infective granulomatous foot disease. The burden of this disease has significantly declined in recent years due to better generalized living conditions. Hence, the diagnosis can be quite often missed by the new generation orthopedic surgeon for other more similar conditions. Early diagnosis and prompt treatment is crucial for better outcome and limb survival. We here present the clinical picture of three such Madura foot cases. Case Series: In this study, three Indian males aged between 40 and 60 years of rural background presented to our department with chronic multiple discharging sinuses of the foot. They were initially treated for several months in their local health centers without any improvement. Finally, they came to our institution where they were thoroughly inspected and underwent various investigations such as magnetic resonance imaging (MRI) and histopathological examination. They were referred across various departments such as dermatology, general surgery and orthopedics, and eventually got correct diagnosis. Treatment was promptly started with oral itraconazole, an antifungal drug, and one patient undergoing additional surgical debulking of the disease which lead to gradual healing of the disease as evident by disappearance of sinuses and return of normal skin in 6-12 months. Conclusion: Madura foot is very characteristic, although it may mimic more prevalent infectious conditions. The characteristic multiple discharging sinuses with extrusions of sulphur granules and MRI findings of "dot in circle" should clinch the diagnosis quickly. Medical therapy should be continued for at least 12 months even if there is resolution of disease in the early or mid-phase of treatment. Debulking of the disease will aid in early recovery and reduce abnormal swelling or appearance of the foot.

Madura's foot: reasons for the delay in diagnosis and consequences for the management (a case report).

Madura foot, relatively easy to diagnose in tropical countries, is very rare and unrecognized in Morocco, causing diagnostic delays. We present the case of a 54-year-old patient with mycetoma for 3 years who initially consulted two general practitioners, then an endocrinologist and finally a dermatologist in order to be diagnosed correctly. The diagnosis of mycetoma based on biological criteria was established at a late stage of irreversible bone lesions; requiring amputation by the orthopedic team. Mycetomas are fungal or bacterial. Delays in diagnosis and care are frequent in Morocco. The diagnosis is based on biology; however, radiological examinations are necessary to assess the extension. The initial treatment is medicinal. Surgery takes place in late stages.

Successful Limb Salvage in a Case of Advanced Long-Standing Eumycetoma of the Foot Using Adjunctive Local Amphotericin B Delivery Through Bioabsorbable Beads.

Mycetoma is a chronic, granulomatous infection mainly involving the foot and is caused either by bacteria (actinomycetoma) or fungi (eumycetoma). Eumycetoma is notoriously resistant, posing a therapeutic challenge. There are no specific treatment guidelines but generally a combination of systemic antifungals and local surgical treatment is the accepted standard. Advanced unresponsive lesions generally require amputation. We present a case of eumycetoma of 15-year duration with extensive involvement of foot including bones. Patient had been advised amputation from various tertiary care centers but we decided to give a limb salvage trial. The patient underwent soft tissue debridement along with oral antifungal therapy. Additionally, amphotericin B-impregnated bioabsorbable beads were inserted locally into the bony cavities to supplement the treatment. There has been no recurrence till date. This case is reported in view of successful limb salvage in an advanced eumycetoma case with an unprecedented use of adjunctive local antifungal delivery.

Surgical Management of Mycetoma in Chad: Experience from the French Forward Surgical Team Deployed in N'Djamena.

Mycetoma is a disease that occurs in the mycetoma belt, between latitudes 15̊ south and 30̊ north. It affects disadvantaged regions with limited access to medical and health facilities. Its general principles of care have changed little and are poorly known. We analyzed the management of mycetoma in Chad by French military surgeons deployed within the Epervier and Barkhane operations. This retrospective descriptive study was conducted among the cohort of Chadian patients managed by the N'Djamena forward surgical team from 2007 to 2018 as part of the medical support to the population. It includes 132 patients who had surgery for mycetoma. Surgical parameters of primary treatment and revisions procedures were analyzed. Postoperative follow-up was at least six months. Amputation was performed in 87/132 (66%) patients. Overall 11 (8.3%) required revision surgery, including 7 (5%) with eumycetoma recurrence. All recurrences occurred in the lower limb. The recurrence rate after excision was 10.2% (5/49) versus 2.3% after amputation (2/87). In the absence of effective and accessible medical treatment, surgery remains the basic treatment for mycetoma. Salvage surgery with local excision should always be considered. However, amputation is the only reliable treatment in cases with late presentation. It should not be proposed too early as limb function is preserved for a long time.