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Mycetoma

Presentation

History

Mycetoma occurs most commonly in people who work in rural areas where they are exposed to acacia trees or cactus thorns containing the etiologic agents that normally live as saprobes. However, the disease has also been found in individuals who work in the city in various occupations.

The classic clinical triad of mycetoma is tumor or soft-tissue swelling, sinus tracts, and characteristic macroscopic grains. The grains typically represent aggregates of the infecting organisms. The earliest sign is often painless subcutaneous swelling. Some patients may give a history of a penetrating injury at the site of involvement.

Several years later, a painless subcutaneous nodule is observed. After some years, massive swelling of the area occurs, with induration, skin rupture, and sinus tract formation.

As the infection spreads to contiguous body parts, old sinuses close and new ones open.

Nearly 20% of patients with mycetoma experience associated pain, usually due to secondary bacterial infection or, less commonly, bone invasion.

Constitutional symptoms and signs of mycetoma are rare.

Patients may report a deep itching sensation.

Physical Examination

Irrespective of the causal agent, the appearance of the mycetoma lesion is consistent. Initially, subcutaneous swelling is present. In a later phase, a subcutaneous nodule develops. Eventually, massive swelling with induration, rupture of the skin, and formation of sinus tracts occur.

The skin is usually darker and firmer than the surrounding areas. Nodules, abscesses, and fistulae draining a clear viscous or purulent exudate can be observed. Granules of the microorganisms may occasionally be seen with the naked eye, as in the case of mycetoma caused by A madurae and M mycetomatis, among others.

In general, eumycetoma is more circumscribed and progresses slower than actinomycetoma.

The most common anatomical locations affected by this disease are the arms and legs, particularly the feet and legs. In Mexico, the next most commonly affected site is the thoracic area, but this varies from country to country. Rarely, mycetoma can also be observed on the buttocks, groin, head, and neck.

See the images below.

Actinomycetoma of the foot (left) and arm (center) caused by Nocardia brasiliensis. Multiple nodules and fistulae are present. Microscopic examination of the pus (right). Granules are observed, which are multilobulated and surrounded by abundant clubs.

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Eumycetoma. Mycetoma of the hand (left). Microscopic features of a Madurella mycetomatis grain are observed (center). Notice the presence of brownish hyphae and intercellular cement (hematoxylin and eosin stain). Macrocolony of another eumycotic agent, Scedosporium apiospermum (Pseudallescheria boydii) (right).

View Media Gallery

Regional lymphadenopathy is unusual. Lymphatic spread of mycetoma to regional nodes occurs in only 1-3% of affected patients. Secondary bacterial infection or a local immunologic reaction may enlarge the regional lymph nodes. Lymphatic obstruction and fibrosis can cause lymphedema and erythema.

Pulmonary mycetoma has been found to develop and progress more rapidly in individuals infected with HIV.

Differential Diagnoses

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Media Gallery

Mycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years.
Frontal view of mycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years.
MRI coronal section of mycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years. On this T1-potentiated image, a large heterogenous mass surrounds the cranium. Bone invasion can be observed only in the area of the zygomatic fossa.
MRI with coronal view of mycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years. The mycetoma mass invades the left parapharyngeal space and almost reaches the lumen of the pharynx.
Actinomycetoma of the foot (left) and arm (center) caused by Nocardia brasiliensis. Multiple nodules and fistulae are present. Microscopic examination of the pus (right). Granules are observed, which are multilobulated and surrounded by abundant clubs.
Eumycetoma. Mycetoma of the hand (left). Microscopic features of a Madurella mycetomatis grain are observed (center). Notice the presence of brownish hyphae and intercellular cement (hematoxylin and eosin stain). Macrocolony of another eumycotic agent, Scedosporium apiospermum (Pseudallescheria boydii) (right).

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Table 1. Fungi Causing Mycetoma

White Grain	Black Grain
Acremonium falciforme	Exophiala jeanselmei
Acremonium kiliense	T grisea
Acremonium recifei	M mycetomatis
Cylindrocarpon destructans	Madurella pseudomycetomatis
Fusarium moniliforme	Leptosphaeria tomkinsii
Fusarium solani	Leptosphaeria senegalensis
Neotestudina rosatii	Pyrenochaeta mackinnonii
P boydii (S apiospermum)	Pyrenochaeta romeroi
----------------	Phlenodomus avramii

Table 2. Microorganisms Causing Actinomycetoma in Humans

Etiologic Agent	Grain
Actinomadura madurae	White, large, 1-5 mm in diameter
Actinomadura pelletieri	Red, hard, 1 mm in diameter
N brasiliensis	White to yellow, multilobed, soft, < 0.5 mm in diameter
N asteroides	Uncommon, white, soft, < 0.5 mm in diameter
Nocardia otitidiscaviarum	White to yellow, lobed, < 0.5 mm in diameter
Nocardia transvalensis	White to yellow, < 0.5 mm in diameter
Nocardia veterana^[24]	--
Nocardia mexicana^[25]	--
N harenae	--
N takedensis	--
Nocardiopsis dassonvillei	White to yellow, < 0.5 mm in diameter
S somaliensis	Yellow, hard, 2 mm in diameter
Streptomyces sudanensis	Yellow, hard, 2 mm in diameter

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Author

Lucio Vera-Cabrera, PhD Laboratorio Interdisciplinario de Investigación Dermatológica, Servicio de Dermatología, Hospital Universitario, UANL, Mexico

Lucio Vera-Cabrera, PhD is a member of the following medical societies: American Society for Microbiology

Disclosure: Nothing to disclose.

Coauthor(s)

Mario C Salinas-Carmona, MD, PhD Chair, Department of Immunology, Universidad Autónoma De Nuevo León, Mexico

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Raphael J Kiel, MD Associate Professor of Medicine, Wayne State University School of Medicine; Associate Professor of Medicine, Oakland University William Beaumont School of Medicine; Consulting Staff, Infectious Diseases Division, William Beaumont Hospital; Consulting Staff, Infectious Diseases Division Providence Hospital

Raphael J Kiel, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Geriatrics Society

Disclosure: Nothing to disclose.

Oliverio Welsh, MD(DrSc) † Former Chair, Emeritus Professor, Department of Dermatology, Universidad Autónoma De Nuevo León, Mexico

Oliverio Welsh, MD(DrSc) is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Susan M Swetter, MD Director, Pigmented Lesion and Melanoma Program, Professor, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Veterans Affairs Palo Alto Health Care System

Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, Women's Dermatologic Society, American Society of Clinical Oncology, Society for Melanoma Research, Eastern Cooperative Oncology Group, American Medical Association, Pacific Dermatologic Association, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Larry I Lutwick, MD, FACP Editor-in-Chief, ID Cases; Moderator, Program for Monitoring Emerging Diseases; Adjunct Professor of Medicine, State University of New York Downstate College of Medicine

Larry I Lutwick, MD, FACP is a member of the following medical societies: American Association for the Advancement of Science, American Association for the Study of Liver Diseases, American College of Physicians, American Federation for Clinical Research, American Society for Microbiology, Infectious Diseases Society of America, Infectious Diseases Society of New York, International Society for Infectious Diseases, New York Academy of Sciences, Veterans Affairs Society of Practitioners in Infectious Diseases

Disclosure: Nothing to disclose.

Margarita Asenjo, MD Associate Professor, Department of Radiology, Medical School of the University of Las Palmas De Gran Canaria, Spain

Disclosure: Nothing to disclose.

Basilio J Anía, MD Associate Professor of Infectious Diseases, Universidad de Las Palmas de Gran Canaria; Consultant in Internal Medicine, Hospital Universitario Dr. Negrín, Spain

Disclosure: Nothing to disclose.

Folusakin O Ayoade, MD Assistant Professor of Clinical Medicine, Division of Infectious Diseases, Department of Medicine, University of Miami, Leonard M Miller School of Medicine; Attending Physician in Infectious Diseases, Jackson Health System; Attending Physician in Infectious Diseases, University of Miami Hospital

Folusakin O Ayoade, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Medical Association, Infectious Diseases - International Research Initiative, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mohammad J Alam, MD Assistant Professor of Medicine, Departments of Internal Medicine, Infectious Disease, and Emergency Medicine, University Health, Louisiana State University School of Medicine in Shreveport; Affiliate Staff Physician, Department of Internal Medicine (Infectious Disease), Schumpert Medical Center

Mohammad J Alam, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Society of Critical Care Medicine, Southern Medical Association

Disclosure: Nothing to disclose.

Mycetoma Clinical Presentation

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