Introduction
Mycetoma or Madura foot is an unique tropical disease affecting skin, subcutaneous tissue and bones commonly foot.1
Characterized by triad of localized swelling, multiple sinus tracts and discharge of coloured grains predisposed by thorn pricks and penetrating injuries.2
The epidemiology of disease characterised by an endemic region located between latitude of 15 degree south and 30 degree north known as Mycetoma belt.3
Classified as actinomycetoma (bacteria) and eumycetoma (fungi).1
Here we report three cases of actinomycetoma foot, treated with antibiotics to create awareness regarding the prevalence of disease.
Case Series Report
Case 1
A 35 year old male admitted with the complaints of swelling and discharge over the right foot for 1 year duration.
On examination
An ill defined nodular swelling of size 10x10x8cm seen over the medial aspect of right foot involving instep with multiple discharging sinuses.
Investigations
Gram stain shows few pus cells and gram positive cocci. Potassium hydroxide mount shows no branched septate hyphae and fungal spores. Fungal culture shows no evidence of fungal filaments seen. X-Ray foot reveals no bony abnormalities. Histopathological examination shows Neutrophillic infiltrate seen surrounded by palisading histiocytes beyond which mixed inflammatory infiltrate comprising lymphocytes, plasma cells, eosinophils, macrophage and fibrosis seen. 4
Treatment
Patient was treated with Welsch regimen of 3 cycles of injection amikacin 15mg/kg IV for 21 days thrice at the interval of 15 days combined with Tab Sulfamethoxazole and trimethoprim (7 & 35mg/kg/day respectively) for 6 months showed satisfying response. 5
Case 2
A 65 year old male admitted with the complaints of swelling and discharge over the left foot for 1 year duration.
On examination
An ill defined diffuse swelling of size 10x10cm seen over the left foot with multiple discharging sinuses.
Investigations
Gram stain shows multiple pus cells and gram positive cocci. Potassium hydroxide mount shows no branched septate hyphae and fungal spores. X-Ray Foot reveals underlying bony abnormalities with osteolytic changes. Histopathological Examination shows multiple sinus tracts are identified along with foci of microabscess admist actinomycetes colony.
Treatment
Patient was treated with modified two step treatment for actinomycetoma with intensive phase of Gentamycin (80mg twice daily intravenously), and Tablet Trimethoprim Sulphamethoxazole (2 tablets of 960mg twice daily) for 4 weeks along with Maintanence Phase (Step 2) Doxyxycline 100mg orally, twice daily)and Tablet Trimethoprim Sulphamethoxazole as above for 6 months.6
Case 3
A 60 year old male admitted with the complaints of swelling with discharge over the right foot for 6 months duration.
On examination
A localized well-defined tender swelling of size 6x6cm present over the dorsomedial aspect of right foot with multiple sinuses discharging white granules.
Discussion
Actinomycetoma caused by bacteria such as Actinomadura madurae, Actinomadura pelletieri etc.
In India prevalence of actinomycetoma is approximately 75%.
Actinomycetoma with high index of suspicion diagnosed at an earlier stage by microbial culture of discharging grains or grains extracted by overnight saline dressing and histopathological examination.
Cutaneous tuberculosis, Osteomyelitis, Kaposis sarcoma can be close differential diagnosis.1
Periodical deeper tissue biopsy useful in partial debulking to assess disease activity.
Combination antibiotic therapy is necessary in case of actinomycetoma along with regular follow up and proper foot care.
Conclusion
Early diagnosis, prompt treatment and detection of underlying bony involvement may save the limb.
Therefore the diagnostic and therapeutic challenges in treating mycetoma foot and the epidemiological data emphasis the necessity to pay more attention to this unique neglected tropical disease.7
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