eMedicine Specialties > Dermatology > Fungal Infections
Eumycetoma (Fungal Mycetoma)
Updated: Jan 15, 2009
Introduction
Background
Eumycetoma is a chronic cutaneous and subcutaneous infection caused by various genera of fungi. Approximately 40% of mycetomas worldwide are eumycotic as opposed to actinomycotic (ie, caused by bacterial actinomycetes). The disease is marked by progressive destruction of soft tissue and nearby anatomic structures.
Gill, who worked at a dispensary in the southern Indian province of Madura, first recognized mycetomas as a disease entity in 1842. Godfrey first documented a case of mycetoma in Madras, India. Native peoples of the province of Madura commonly called the disease Madura foot. In 1860, Carter, who established the fungal etiology of this disorder, first proposed the term mycetoma.1 In 1872, Carter further proposed the terms melanoid and ochroid in an attempt to classify the disease into 2 varieties on the basis of the black or pale-colored granules (ie, grains, sclerotia) produced by the etiologic agents.2
Pathophysiology
The foot is the most common site of infection, and 70% of all mycetomas affect the foot. Other reported sites of involvement include the upper extremities, trunk, buttocks, eyelids, lacrimal glands, paranasal sinuses, mandible, scalp, neck, perineum, and testes. The disease is initially limited to the skin and subcutaneous tissue but may eventually spread through the fascial planes to contiguous structures such as muscle, bone, blood and lymphatic vessels, and nerves. Rarely, the disease may spread to the regional lymph nodes or viscera.
Frequency
United States
Sporadic cases have been reported in North America. In the United States, epidemiologic data from 1896-1964 include only 30 cases of eumycetoma, with the highest incidence in the Southwest.3 Mycetoma is common in Mexico; in the United States, physicians in Texas and other border states are most likely to encounter patients with mycetoma.
International
Eumycetoma is mainly a disease of the tropical and subtropical zones especially between the Tropic of Cancer and the Tropic of Capricorn, that is, between the latitudes 15° S and 30° N. Eumycetoma is endemic in India, parts of Africa (eg, Sudan,4 Senegal, Somalia, Nigeria, Zaire, Chad), Pakistan, Yemen, Mexico, Central America, South America (eg, Guatemala, Venezuela, Colombia, Brazil), and Indonesia.
Mortality/Morbidity
Eumycetoma can be associated with significant morbidity in terms of gradual enlargement and deformity of the infected site. Severe involvement of the lower extremity may impair ambulation.
Sex
The disease incidence is higher in males than females, with a ratio of 4-5:1.
Age
The disease incidence is highest in persons aged 10-40 years.
Clinical
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
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 Media Files 1-2).
- 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.
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 that cause eumycetoma include the following:
- Those with a white-to-yellow granule
- Acremonium species
- Aspergillus nidulans
- Aspergillus flavus
- Cylindrocarpon cyanescens
- Cylindrocarpon destructans
- Fusarium species
- Neotestudina rosatii
- Polycytella hominis
- P boydii
- Those with a black granule
- Corynespora cassicola
- Curvularia species
- Exophiala jeanselmei
- L senegalensis
- L tompkinsii
- M grisea
- M mycetomatis
- Phialophora verrucosa5
- Plenodomus auramii
- Pyrenochaeta mackinnonii
- Pyrenochaeta romeroi
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References
Carter HV. On a new and striking form of fungus disease principally affecting the foot and prevailing endemically in many parts of India. Transactions of the Medical and Physical Society of Bombay. 1860;6:104-42.
Carter HV. On mycetoma or the fungus disease of India. London, England: J & A Churchill; 1874.
Green WO Jr, Adams TE. Mycetoma in the United States; a review and report of seven additional cases. Am J Clin Pathol. Jul 1964;42:75-91. [Medline].
Abbott P. Mycetoma in the Sudan. Trans R Soc Trop Med Hyg. Jan 1956;50(1):11-24; discussion, 24-30. [Medline].
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. Feb 1995;32(2 Pt 2):311-5. [Medline].
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. Dec 2003;41(12):5813-6. [Medline].
Gabhane SK, Gangane N, Anshu. Cytodiagnosis of eumycotic mycetoma: a case report. Acta Cytol. May-Jun 2008;52(3):354-6. [Medline].
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].
Degavre B, Joujoux JM, Dandurand M, Guillot B. First report of mycetoma caused by Arthrographis kalrae: successful treatment with itraconazole. J Am Acad Dermatol. Aug 1997;37(2 Pt 2):318-20. [Medline].
Lee MW, Kim JC, Choi JS, Kim KH, Greer DL. Mycetoma caused by Acremonium falciforme: successful treatment with itraconazole. J Am Acad Dermatol. May 1995;32(5 Pt 2):897-900. [Medline].
Lacroix C, de Kerviler E, Morel P, Derouin F, Feuilhade de Chavin M. Madurella mycetomatis mycetoma treated successfully with oral voriconazole. Br J Dermatol. May 2005;152(5):1067-8. [Medline].
N'diaye B, Dieng MT, Perez A, Stockmeyer M, Bakshi R. Clinical efficacy and safety of oral terbinafine in fungal mycetoma. Int J Dermatol. Feb 2006;45(2):154-7. [Medline].
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. Mar 1992;14 Suppl 1:S68-76. [Medline].
Hay RJ, Mackenzie DW. Mycetoma (madura foot) in the United Kingdom--a survey of forty-four cases. Clin Exp Dermatol. Sep 1983;8(5):553-62. [Medline].
Hay RJ, Mahgoub ES, Leon G, al-Sogair S, Welsh O. Mycetoma. J Med Vet Mycol. 1992;30 Suppl 1:41-9. [Medline].
Mahgoub ES. Mycetoma. Semin Dermatol. 1985;4:230-9.
Mahgoub ES, Murray IG. Mycetoma. London, England: William Heinemann Medical Books; 1973:1-5, 47-53.
Mariat F, Destombes P, Segretain G. The mycetomas: clinical features, pathology, etiology and epidemiology. Contrib Microbiol Immunol. 1977;4:1-39. [Medline].
McGinnis MR. Mycetoma. Dermatol Clin. Jan 1996;14(1):97-104. [Medline].
Murray PR, ed. Manual of Clinical Microbiology. 7th ed. Washington, DC: Amercian Society for Microbiology; 1999:1318-26.
Rippon JW. Medical mycology: the pathogenic fungi and the pathogenic actinomycetes. Philadelphia, Pa: WB Saunders; 1988:80-118.
Welsh O. Mycetoma. Current concepts in treatment. Int J Dermatol. Jun 1991;30(6):387-98. [Medline].
Zaias N, Taplin D, Rebell G. Mycetoma. Arch Dermatol. Feb 1969;99(2):215-25. [Medline].
Further Reading
Keywords
eumycetoma, Madura foot, maduromycosis, fungal mycetoma, eumycotic mycetoma, melanoid mycetoma, ochroid mycetoma
