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Eumycetoma (Fungal Mycetoma) Clinical Presentation

  • Author: George Turiansky, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Aug 17, 2015
 

History

Many cases are painless, although painful lesions may prompt the individual to seek medical attention. Gradual enlargement of the affected site and difficulties with ambulation may also prompt affected persons to seek care. Predisposing factors include the following:

  • History of trauma
  • Walking barefoot
  • Agricultural work
  • Poor personal hygiene
  • Poor nutrition
  • Wounds or multiple infections
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Physical

The foot is the most common site of infection; 70% of all mycetomas affect the foot. Other reported sites of involvement include the following:

  • Upper extremities
  • Trunk
  • Buttocks
  • Eyelids
  • Lacrimal glands
  • Paranasal sinuses
  • Mandible
  • Scalp
  • Neck
  • Perineum
  • Testes

The disease is initially limited to the skin and subcutaneous tissue but may eventually spread through the fascial planes to contiguous structures, as follows:

  • Muscle
  • Bone
  • Blood and lymphatic vessels
  • Nerves

Rarely, the disease may spread to the regional lymph nodes or viscera.

Eumycetoma is characterized by the clinical triad of tumefaction, draining sinuses, and granules (see images below).

Eumycetoma of the leg with tumefaction, deformity, Eumycetoma of the leg with tumefaction, deformity, and multiple sinus tracts in a patient from Costa Rica. Courtesy of Mervyn L. Elgart, MD, Washington, DC.
Eumycetoma of the foot with tumefaction, deformity Eumycetoma of the foot with tumefaction, deformity, and multiple sinus tracts. Courtesy of Mervyn L. Elgart, MD, Washington, DC.

The disease usually begins as a painless swelling or thickening of the skin and subcutaneous tissue. As the disease gradually progresses over months or years, the initial lesion enlarges and eventually becomes tumorous. The overlying skin may be smooth, dyspigmented, or shiny.

Abscesses and sinus tracts develop over time and may contain a serosanguineous or seropurulent discharge, which may contain white-to-yellow or black granules. Granules are firm 0.2- to 5-mm aggregates of organized vegetative, septate hyphae, which often are embedded in a matrix cement substance. These granules are usually macroscopic and are observed in the lesional tissue and in sinus tracts. The color of the dark grains is thought to be due to melanin, host protein, and dark debris. Regional lymphadenitis secondary to bacterial superinfection of the lesion may be present.

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Causes

Agents that cause eumycetoma are primarily saprophytic microorganisms that are found in the soil and on plant matter. Healthy persons become inoculated with these agents as a result of the traumatic implantation of thorns, splinters, and other plant matter.

Pseudallescheria boydii is the most common etiologic agent of eumycetoma in the United States. Madurella mycetomatis accounts for most cases worldwide. Madurella grisea is a common etiologic agent in South America. Leptosphaeria senegalensis and Leptosphaeria tompkinsii are common causes of eumycetoma in West Africa. In general, the geographic distribution of the various mycetoma agents is related to the amount of rainfall and other climatic conditions. Each geographic region has a different list of most common agents.

Fungi with a white-to-yellow granule that cause eumycetoma include the following:

  • Acremonium species
  • Aspergillus nidulans
  • Aspergillus flavus
  • Cylindrocarpon cyanescens
  • Cylindrocarpon destructans
  • Fusarium species
  • Neotestudina rosatii
  • Polycytella hominis
  • P boydii

Fungi with a black granule that cause eumycetoma include the following:

  • Cladophialophora bantiana [5]
  • Corynespora cassicola
  • Curvularia species
  • Exophiala jeanselmei
  • L senegalensis
  • L tompkinsii
  • M grisea
  • M mycetomatis
  • Phialophora verrucosa [6]
  • Plenodomus auramii
  • Pyrenochaeta mackinnonii
  • Pyrenochaeta romeroi [7]
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Contributor Information and Disclosures
Author

George Turiansky, MD Professor, Department of Dermatology, Uniformed Services University of the Health Sciences

George Turiansky, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, Association of Professors of Dermatology, Ukrainian Medical Association of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Canadian Dermatology Association

Disclosure: Nothing to disclose.

References
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  2. Carter HV. On mycetoma or the fungus disease of India. London, England: J & A Churchill; 1874.

  3. Green WO Jr, Adams TE. Mycetoma in the United States; a review and report of seven additional cases. Am J Clin Pathol. 1964 Jul. 42:75-91. [Medline].

  4. Abbott P. Mycetoma in the Sudan. Trans R Soc Trop Med Hyg. 1956 Jan. 50(1):11-24; discussion, 24-30. [Medline].

  5. Werlinger KD, Yen Moore A. Eumycotic mycetoma caused by Cladophialophora bantiana in a patient with systemic lupus erythematosus. J Am Acad Dermatol. 2005 May. 52(5 Suppl 1):S114-7. [Medline].

  6. Turiansky GW, Benson PM, Sperling LC, Sau P, Salkin IF, McGinnis MR, et al. Phialophora verrucosa: a new cause of mycetoma. J Am Acad Dermatol. 1995 Feb. 32(2 Pt 2):311-5. [Medline].

  7. Mathuram Thiyagarajan U, Bagul A, Nicholson ML. A nodulo-cystic eumycetoma caused by Pyrenochaeta romeroi in a renal transplant recipient: A case report. J Med Case Reports. 2011 Sep 14. 5(1):460. [Medline]. [Full Text].

  8. Ahmed AO, Desplaces N, Leonard P, Goldstein F, De Hoog S, Verbrugh H, et al. Molecular detection and identification of agents of eumycetoma: detailed report of two cases. J Clin Microbiol. 2003 Dec. 41(12):5813-6. [Medline].

  9. Hemalata M, Prasad S, Venkatesh K, Niveditha SR, Kumar SA. Cytological diagnosis of actinomycosis and eumycetoma: a report of two cases. Diagn Cytopathol. 2010 Dec. 38(12):918-20. [Medline].

  10. Gabhane SK, Gangane N, Anshu. Cytodiagnosis of eumycotic mycetoma: a case report. Acta Cytol. 2008 May-Jun. 52(3):354-6. [Medline].

  11. Ahmed M, Sureka J, Chacko G, Eapen A. MRI findings in cranial eumycetoma. Indian J Radiol Imaging. 2011 Oct. 21(4):261-3. [Medline].

  12. Mahgoub ES, Gumaa SA. Ketoconazole in the treatment of eumycetoma due to Madurella mycetomii. Trans R Soc Trop Med Hyg. 1984. 78(3):376-9. [Medline].

  13. Degavre B, Joujoux JM, Dandurand M, Guillot B. First report of mycetoma caused by Arthrographis kalrae: successful treatment with itraconazole. J Am Acad Dermatol. 1997 Aug. 37(2 Pt 2):318-20. [Medline].

  14. Lee MW, Kim JC, Choi JS, Kim KH, Greer DL. Mycetoma caused by Acremonium falciforme: successful treatment with itraconazole. J Am Acad Dermatol. 1995 May. 32(5 Pt 2):897-900. [Medline].

  15. Lacroix C, de Kerviler E, Morel P, Derouin F, Feuilhade de Chavin M. Madurella mycetomatis mycetoma treated successfully with oral voriconazole. Br J Dermatol. 2005 May. 152(5):1067-8. [Medline].

  16. N'diaye B, Dieng MT, Perez A, Stockmeyer M, Bakshi R. Clinical efficacy and safety of oral terbinafine in fungal mycetoma. Int J Dermatol. 2006 Feb. 45(2):154-7. [Medline].

  17. Diaz M, Negroni R, Montero-Gei F, Castro LG, Sampaio SA, Borelli D, et al. A Pan-American 5-year study of fluconazole therapy for deep mycoses in the immunocompetent host. Pan-American Study Group. Clin Infect Dis. 1992 Mar. 14 Suppl 1:S68-76. [Medline].

 
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Eumycetoma of the leg with tumefaction, deformity, and multiple sinus tracts in a patient from Costa Rica. Courtesy of Mervyn L. Elgart, MD, Washington, DC.
Eumycetoma of the foot with tumefaction, deformity, and multiple sinus tracts. Courtesy of Mervyn L. Elgart, MD, Washington, DC.
 
 
 
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