eMedicine Specialties > Dermatology > Fungal Infections

Eumycetoma (Fungal Mycetoma): Treatment & Medication

Author: George Turiansky, MD, Associate Professor, Department of Dermatology, Uniformed Services University of the Health Sciences; Director, National Capital Consortium Dermatology Residency Program, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Jan 15, 2009

Treatment

Medical Care

  • Treatment of eumycetoma remains problematic.
    • Historically, the treatment of eumycetoma has included surgical treatment, medical treatment, or both.
    • Combined surgical and medical treatment appears to be the management option of choice.
  • Antifungal therapy has variable results.
    • The sensitivity of organisms to antifungal drugs in vitro is not necessarily correlated with the in vivo response.
    • Amphotericin B has minimal or no effect on eumycetoma organisms.
    • Anecdotal reports of successful treatment with griseofulvin and dapsone exist.
    • In one study, a case of eumycetoma due to M grisea initially responded to fluconazole 400 mg/d but worsened after the patient stopped the treatment. In the same report, 2 other cases due to M mycetomatis and P boydii had either slight improvement or only transient clinical improvement with fluconazole 200-400 mg/d for 3 months. These cases were classified as nonresponsive.
    • Azole antifungal agents such as ketoconazole have some effectiveness. Mahgoub and Gumaa demonstrated that ketoconazole is effective in the treatment of eumycetoma caused by M mycetomatis.8 They treated 13 patients with oral ketoconazole 200-400 mg/d; 5 patients were cured, and 4 patients improved. The median treatment duration was 12.9 months, with a treatment range of 3-36 months. Cures were noted with the higher dosages of ketoconazole.
    • Itraconazole is variably effective in the treatment of eumycetoma due to various organisms.9,10  One case of eumycetoma due to M mycetomatis without bony involvement was successfully treated with oral voriconazole at 600 mg/d, with a 4-year disease free follow-up.11
    • A study by N'Diaye et al showed that high-dose terbinafine (500 mg bid) for 24-48 weeks was generally well tolerated. In the investigators' overall opinion at the end of the study, of 20 eumycetoma patients who completed the study, 5 patients were clinically cured and 11 were clinically improved.12

Surgical Care

  • Treatment in the past has included amputation of the affected limb or other radical surgery.
  • Although surgical treatment alone results in recurrence rates as high as 80%, surgical resection with a wide surgical margin of uninfected tissue may be useful in early, small lesions without bony involvement.
  • Surgical debulking together with oral antifungal treatment may be necessary with chronic extensive lesions.

Medication

The use of various antifungal agents in the treatment of eumycetoma has been reported. Imidazole antifungal agents appear to be the agents of choice. Of the azole group of antifungal agents, ketoconazole appears to be antifungal agent of choice, although isolated reports of successful treatment with itraconazole exist.

Antifungal agents

Reportedly, imidazole antifungal agents are variably effective in the treatment of eumycetoma when they are used alone or in conjunction with surgical therapy.


Ketoconazole (Nizoral)

Synthetic imidazole antifungal agent. Broad-spectrum agent known to be a potent inhibitor of cytochrome P-450 3A4 enzyme system in vitro. Inhibition of this system impairs synthesis of ergosterol, a vital component of fungal cell membranes.

Adult

200-600 mg PO qd

Pediatric

<2 years: Not established
>2 years: 3.3-6.6 mg/kg PO qd

As a CYP3A4 inhibitor (P450 metabolism), many drugs have interactions when coadministered with ketoconazole; isoniazid may decrease bioavailability; rifampin coadministration decreases effects of either drug; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dose can be adjusted); may decrease theophylline levels; coadministration with cisapride can cause adverse cardiovascular effects (possibly death); coadministration of triazolam or midazolam is contraindicated due to possible increased sedative and hypnotic effects; coadministration of oral HMG-CoA reductase inhibitors lovastatin and simvastatin is contraindicated due to potential risk of rhabdomyolysis and myopathy

Documented hypersensitivity; fungal meningitis; concurrent use with astemizole, terfenadine, cisapride, or oral triazolam

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hepatic toxicity, including rare fatalities, reported; monitor hepatic function at baseline and during treatment; carefully monitor patients requiring prolonged treatment, those taking concurrent potentially hepatotoxic drugs, and those with preexisting liver disease; may elevate plasma concentrations of concomitant drugs; various classes of drugs can decrease antifungal plasma drug concentrations (thoroughly review package inserts prior to concomitant use of these antifungal agents); anaphylaxis rare; mild GI intolerance; imidazoles can interfere with production of endogenous steroids, resulting in irregular bleeding in women and gynecomastia in men; administer antacids, anticholinergics, or H2-blockers at least 2 h after dose


Itraconazole (Sporanox)

Triazole antifungal agent known to be a potent inhibitor of the cytochrome P-450–dependent synthesis of ergosterol in vitro. Slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.

Adult

100-300 mg PO qd

Pediatric

Solution
<6 months: Not established
6 months-12 year: 5 mg/kg/d PO for 2 wk
Cap
<3 years: Not established
3-16 years: 100 mg/d PO
>16 years: Administer as in adults

As a CYP3A4 inhibitor (P450 metabolism), many drugs have interactions when coadministered with itraconazole; antacids may reduce absorption; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; high doses may increase tacrolimus and cyclosporine plasma concentrations; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (eg, lovastatin, simvastatin); cisapride coadministration can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce levels (phenytoin metabolism may be altered)

Documented hypersensitivity; coadministration with cisapride, dofetilide, oral midazolam, pimozide, levacetylmethadol (levomethadyl), quinidine, lovastatin, simvastatin, triazolam, ergot alkaloids metabolized by CYP3A4, such as dihydroergotamine, ergometrine (ergonovine), methylergometrine (methylergonovine); congestive heart failure or history of congestive heart failure; pregnant women or women contemplating pregnancy

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic insufficiency; serious adverse effect includes neutropenic disorder

More on Eumycetoma (Fungal Mycetoma)

Overview: Eumycetoma (Fungal Mycetoma)
Differential Diagnoses & Workup: Eumycetoma (Fungal Mycetoma)
Treatment & Medication: Eumycetoma (Fungal Mycetoma)
Follow-up: Eumycetoma (Fungal Mycetoma)
Multimedia: Eumycetoma (Fungal Mycetoma)
References
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References

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Further Reading

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Keywords

eumycetoma, Madura foot, maduromycosis, fungal mycetoma, eumycotic mycetoma, melanoid mycetoma, ochroid mycetoma

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Contributor Information and Disclosures

Author

George Turiansky, MD, Associate Professor, Department of Dermatology, Uniformed Services University of the Health Sciences; Director, National Capital Consortium Dermatology Residency Program, Walter Reed Army Medical Center
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, and Ukrainian Medical Association of North America
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Hogan, MD, Clinical Professor of Internal Medicine (Dermatology), NOVA Southeastern University; 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, and Canadian Dermatology Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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