Mycetoma

Description:

Mycetoma (the Madura foot, maduromycosis, fikomitsetoma) - the focal, chronic, slowly progressing, often painless destructive disease which begins in hypodermic cellulose and extends to the next body parts.

In 1842 Gill described a disease at the patients observed in the Indian province Madura and called this disease "the Madura foot" or a maduromitsetoma, having allocated the Madurella and Actinomadura activator. In 1874 Carter gave a complete description of a disease in India. Now the mycetoma is eurysynusic in tropical regions of the whole world and less often meets in zones a temperate climate. Most often the disease meets in Mexico, Saudi Arabia, Venezuela, Yemen and in the states located near the Sahara, as if "belt" reaching from Senegal for the western coast - through Mali, Niger, Congo and Sudan – to Somalia on east coast of Africa. The most frequent causal agents of mycetomas in North America - Ps. boidii which is found in the soil of the USA and Canada. M. mycetomatis and S. somaliniensis dominate in tropical regions of Africa and India, and N. brasiliensis and A. madurae - the most frequent activator of mycetomas in Mexico, Central and South America. N. asteroides prevails in Japan. From 21 cases (1998) diseases of a mycetoma described by Kornysheva V. G. in the territory of Russia, a half was observed at residents of the Caucasus, 6 (29%) were residents of Azerbaijan and 4(9%) - residents of St. Petersburg, a third of patients were inhabitants of the European part of the former USSR, isolated cases are described at residents of Siberia, the Far East, Central Asia, the Urals and Altai. Villagers and construction workers made 50% of patients. The foot mycetoma caused by Ps is described. voidii at the resident of Grozny and the forearm mycetoma at the resident of Tiraspol (44 years) caused by Strept. somaliniensis which arose after the open fracture got during stay of the patient in the Far East.

Mycetoma reasons:

The term of an aktinomitsetom came from their activator - aktimitset – the bacteria forming the branching mycelium. When causal agents are mushrooms, such process is called an eumitsetoma. Activators of an eumitsetoma include: Pseudoallescheria boydii, Madurella mycetomatis, Madurella griea, Exophiala jeanselnaei, Pyrenodueta romeroi, Leptosphaeria senegalensis, Neotestudine rosetee, Arthrographis kalrae, Fusarium spp., Corynespora, Polycitella, Cylindracapron, Curvularis and Acremonium. Activators of an aktinomitsetoma include the following aerobic actinomycetes: Actinomadura madurae, Actinomadura pelletierii, Streptomyces somaliensis, Nocardia brasiliensis, Nocardia asteroides, Nocardia otitis-caviarum, Nocardia transvalensis and Nocardia dassonvillei. The microorganisms causing mycetomas differ in geographical distribution, color of druses and, distinctions in the clinical manifestations caused by them pathological processes are possible.

Risk factors - traumatization of the lower extremities at circulation barefoot or in the footwear which is a little protecting skin.

Pathogeny:

The mycetoma arises after penetration into a wound or a graze of the soil or the other infected substrate (usually decaying plant residues).

Local defeats with hypostases and multiple abscesses with fistulas are characteristic.

Defeats of a respiratory path are characteristic of inhalation defeats.

Defeats of feet are most frequent, infection of wounds of any part of a body is possible.
Sometimes observe the secondary damages of bones and bacterial superinfections which are often coming to an end letalno.

Mycetoma symptoms:

The mycetoma is most often met at men aged from 20 up to 40 years. However it is necessary to remember that in local regions the disease occurs both at children and at elderly people. The ratio of men to women makes 5:1 (according to other data 3,7:1). Often it is found in farmers and other workers of agricultural regions, in bedouins and nomads who often injure skin prickles and splinters. The most frequent places of an infection – foot, usually the back of foot (79%). For the unclear reason for a thicket the left foot is surprised. Painless massive tumorous consolidations of foot "are honeycombed" fistular hodyam. Usually complaints are rare, and temperature reaction arises in cases of accession of a consecutive bacterial infection. Cases with involvement not of feet arise owing to work with the earth, a seat and lying on it and includes other parts of legs, a torso, all parts of hands, the head, a neck and buttocks. When a pilar part of the head is involved whether the infection begins usually on a back part of a neck and on a forehead.

Early manifestations – the small painless papules and nodes on a sole or the back of foot progressing in a size. Process develops at aktinomitsetoma quicker, than at eumitsetoma. Skin manifestations in the form of hypostasis, abscess and formation of fistulas. When process extends, the similar centers observe also in the next parts. The old fistular courses gradually begin to live and are closed, but in other places new open. Thus, old it is long the proceeding mycetomas are characterized by the multiple begun to live hems and fistulas. After many months and years of a current there is a destruction of deep fabrics, including bones that is presented as generalized hypostasis which, however, in most cases remains painless, excepting about 15% of the patients addressing because of a pain syndrome.

The disease progresses as focal fabric educations with formation of a tumor, sites of suppuration and hems. Sometimes the set of the fistular courses from which pus with grains is emitted forms. The infection never extends gematogenno, however there can be a distribution on lymphatic ways - to regional lymph nodes and to the subsequent suppuration. Such cases demand repeated surgical interventions. The involved fabrics can become soiled also for the second time bacteria. It is the best of all to define prevalence of defeat of soft tissues on the magnetic and resonant tomography (MRT).

In bones through a periosteum the mass of grains can gradually pass into a bone tissue and marrow, and sometimes in such there is a spontaneous pathological change. X-ray inspection defines multiple osteomiyelitichesky defeats which can be described as cavities and periosteal formations of a new bone tissue. Also sometimes observe the osteoporosis caused by pressure of surrounding edematous fabrics and an atrophy. Owing to chronic periosteal fibrosis joints sometimes tugopodvizhna. At mycetomas of a skull observed the diffusion thinning of bones caused by pressure of skin educations and sometimes trabeculas in some places, though it is very rare, there can be also small areas of ossifluence.

Diagnosis:

In typical cases the following triad of symptoms allows to assume existence of a mycetoma:
1. Dense hypostases.
2. The multiple fistular courses with the pus containing grains (druse).
3. Typical localization on foot.

The characteristic grains which are emitted from fistulas have diameter of 0,2-3,0 mm and can be black, white, yellow, pink and red – depending on the activator. For example, grains of types Actinomyces, Nocardia, and also P. boydii – white or yellowish whereas Madurella forms black grains. Grains are difficult to be considered directly on glass and their fixing in paraffin and a section in many places is required. Coloring by hematoxylin-eosine adequately defines grains and well is suitable for diagnosis. Coloring across Gram well finds the branching mycelium in actinomycotic druses, and coloring according to Gomori-Grokott and Schiff reaction defines wider mycelium at eumitsetoma. Samples often differ on color, the sizes, density and content of hematoxylin in grains.

More exact diagnosis depends on allocation of culture of a causal microorganism – crops of grains. Grains of mushrooms as far as it have to be perhaps free from foreign bacteria and. The wedge-shaped deep biopsy of a mycetoma allows to receive good stuff as for a histologic, and cultural research. Before the placement on a medium, grains have to be washed out in 70% alcohol and several times - in sterile normal saline solution. The research of a bioptat is more preferable than crops of allocations from fistulas as those may contain superficial microorganisms or to be the dead. For primary allocation actinomycotic grains grow up on the Lowenstein-Jensen environment, and mushroom – on a blood agar. The Aloes environment without antibiotics is suitable for subcultures.

Usually prepare two cups: one is located at 37 °C, and another at 26 °C. Characteristic colonies have to develop within 10 days.

Bacterial colonies usually granular or as heads. At the same time fungal colonies either velvety or fluffy. Further identification is carried out at microscopy of mushrooms in lactophenol blue and bacteria in coloring across Gram and Tsilyu-Nielsen. Serological diagnosis is available only in the specialized centers.

Differential diagnosis.
In local areas painless typical hypodermic consolidations have to be considered as a probable mycetoma with the subsequent research even in the absence of fistulas. In cases when the mycetoma involves bones, it can be confused with chronic bacterial osteomyelitis. A botryomycosis – the persistent bacterial infection which is shown as dense fibrous hypodermic educations with fistulas reminds also too a mycetoma as even grains find in the form of pus in fabric samples. The botryomycosis meets more often, than a mycetoma, and at it sometimes internals also are involved in process. An etiological agent of a botryomycosis are various gram-positive cocci (staphylococcus, streptococci) and gram-negative bacteria (E. coli, Pseudomonas spp., Proteus sp.). In the absence of fistulas the mycetoma has to be differentiated from benign and malignant tumors, cold abscesses or from the granulomas arising in the field of pricks.

Treatment of a mycetoma:

The educational program that there were addresses to the doctor as soon as possible is necessary. Surgical treatment which is still preferred by some doctors usually conducts to an immediate recurrence or the distorted results concerning safety of life. The mycetoma in all its stages can give in only to conservative therapy or in a combination with local surgical intervention. In surgical interventions perform only operations on reduction of volume, and amputations and desarticulations have to be excluded. Success of therapy depends not only on a difference between aktinomitsetoma and eumitsetoma, but also also on types of the activator.

In all cases of an aktinomitsetoma use combinations of two drugs. One of them always streptomycin sulfate in a dose of 14 mg/kg daily within one month and every other day further. At patients with the mycetoma caused by A. madurae apply dapsone orally in a dose of 1,5 mg/kg in the morning and in the evening. At the mycetomas caused by S. somaliensis too carry out treatment at first by dapsone, but in the absence of result after 1 month change for co-trimoxazole (Biseptolum) in tablets 23 mg/kg/day for two receptions. The mycetomas caused by A. pelletierii better answers streptomycin and co-trimoxazole, the same treats N. brasiliensis. Nevertheless, some mycetomas caused by Nocardia in America treat co-trimoxazole and dapsone. Amikacin is drug of the second line that is connected with the available side effects. Treatment consists in introduction of 15 mg/kg/day for two receptions – 3 weeks and Biseptolum of 35 mg/kg/day – 5 weeks. The cycle is repeated twice, and it is rare when carrying out a third year is required. Eumitsetoma called by M. mycetomatis often 200 mg 2 times a day and operational local cleanings answer on кетоконазол. There are data on successful use of an itrakonazol of 200 mg 2 times a day. The exceptional cases of mycetomas caused by Acremonium fasciforme well answer Aspergillus flavus or Fusarium on итраконазол in a dose of 200 mg 2 times a day. Intravenous administration of liposomal Amphotericinum In was used at the mycetomas caused by M. grisea and Fusarium spp. In the general dose of 3,5 g and with the maximum day dose of 3 mg/kg. In the described case only temporary remission was received.

In all cases of medicamentous therapy treatment was continued by not less than 10 months. Though side effects are also rare, patients depending on the choice of medicine should do regularly the general clinical blood tests, urine, to define biochemical indicators of function of a liver.

Current and forecast
Are defined by localization and prevalence of process. The current is chronic, 10–20 years last.

Defeats of foot or brush often lead to amputation. Death comes from sepsis or an intercurrent disease.