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Dermatologic Manifestations of Mycetoma Medication

  • Author: Oliverio Welsh, MD(DrSc); Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jul 26, 2013
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and to eradicate the disease.

When prescribing imidazole antifungals, considering interactions with other medications (eg, rifampin, cyclosporin A, warfarin) that interact with cytochrome P450 is important. Azole administration is contraindicated during pregnancy.

Aminoglycosides can induce ototoxicity and renal damage; therefore, the administration of these drugs must include an evaluation of auditory and kidney function during treatment.

Sulfonamides can produce gastritis, photosensitivity, and a skin eruption that can sometimes be severe (eg, toxic epidermal necrolysis, Stevens-Johnson syndrome). Hematologic adverse effects, including methemoglobinemia, can develop as adverse reactions to these drugs.

The main adverse effect of amphotericin B is renal impairment that can lead to permanent kidney damage. Other adverse reactions include ECG changes, hypokalemia, anemia, thrombocytopenia, and leukopenia.

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Antifungals

Class Summary

Ketoconazole, itraconazole, amphotericin B, and terbinafine are most commonly used to treat mycetoma. When systemic agents are administered, monitoring patients for adverse effects and complications common to the drug is important. Therapy is suggested for 1-2 years (or greater) for complete eradication, unless adverse effects warrant cessation of medication.

Ketoconazole (Nizoral)

 

Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak and resulting in fungal cell death. Available in 200-mg tablets.

Itraconazole (Sporanox)

 

Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes. Available in 100-mg capsules.

Amphotericin B (AmBisome)

 

Produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death.

Terbinafine (Lamisil)

 

Inhibits squalene epoxidase, which decreases ergosterol synthesis, causing fungal cell death. Use medication until symptoms significantly improve.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

 

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. In certain anatomical sites (eg, thorax, head), extensive lesions, and cases recalcitrant to this antibiotic, add amikacin and maintain for 5-20 wk (or longer), depending on the clinical response and renal and auditory adverse effects.

Amikacin (Amikin)

 

Irreversibly binds to 30S subunit of bacterial ribosomes; blocks recognition step in protein synthesis; causes growth inhibition. Use the patient's IBW for dosage calculation. The current treatment of actinomycetoma is every 2 or 3 wk. Periodic audiometric and CrCl testing must be performed.

Netilmicin (Netromycin)

 

For gram-negative bacterial coverage of infections resistant to gentamicin. Irreversibly binds to 30S subunit of bacterial ribosomes; blocks recognition step in protein synthesis; causes growth inhibition.

Use IBW for dose calculation.

Minocycline (Dynacin, Minocin)

 

Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species.

Amoxicillin and clavulanate (Augmentin)

 

Drug combination treats bacteria resistant to beta-lactam antibiotics. Indicated for skin and skin structure infections caused by beta-lactamase–producing strains of Staphylococcus aureus. For children >3 mo, dose on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until a child weighs >40 kg.

Streptomycin

 

Aminoglycoside antibiotic recommended when less potentially hazardous therapeutic agents are ineffective or contraindicated.

Imipenem and cilastatin (Primaxin)

 

For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of potential for toxicity.

Rifampin (Rifadin, Rimactane)

 

Inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Supplied as 150- or 300-mg cap. Rifampin for injection USP contains rifampin 600 mg, sodium formaldehyde sulfoxylate 10 mg, and sodium hydroxide to adjust pH to 7.8-8.8. Rifampin for injection is for IV infusion only.

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Contributor Information and Disclosures
Author

Oliverio Welsh, MD(DrSc) Former Chair, Active Emeritus Professor, Department of Dermatology, Universidad Autónoma De Nuevo León, Mexico

Oliverio Welsh, MD(DrSc) is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Lucio Vera-Cabrera, PhD Laboratorio Interdisciplinario de Investigación Dermatológica, Servicio de Dermatología, Hospital Universitario, UANL, Mexico

Lucio Vera-Cabrera, PhD is a member of the following medical societies: American Society for Microbiology

Disclosure: Nothing to disclose.

Mario C Salinas-Carmona, MD, PhD Chair, Department of Immunology, Universidad Autónoma De Nuevo León, Mexico

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

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

Susan M Swetter, MD Director, Pigmented Lesion and Melanoma Program, Professor, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Veterans Affairs Palo Alto Health Care System

Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, Women's Dermatologic Society, American Society of Clinical Oncology, Society for Melanoma Research, Eastern Cooperative Oncology Group, American Medical Association, Pacific Dermatologic Association, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

References
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Actinomycetoma of the foot (left) and arm (center) caused by Nocardia brasiliensis. Multiple nodules and fistulae are present. Microscopic examination of the pus (right). Granules are observed, which are multilobulated and surrounded by abundant clubs.
Eumycetoma. Mycetoma of the hand (left). Microscopic features of a Madurella mycetomatis grain are observed (center). Notice the presence of brownish hyphae and intercellular cement (hematoxylin and eosin stain). Macrocolony of another eumycotic agent, Scedosporium apiospermum (Pseudallescheria boydii) (right).
Table 1. Fungi Causing Mycetoma
White grain Black grain
Acremonium falciforme Exophiala jeanselmei
Acremonium kiliense Madurella grisea
Acremonium recifei M mycetomatis
Cylindrocarpon destructans M pseudomycetomatis
Fusarium moniliforme Leptosphaeria tomkinsii
Fusarium solani Leptosphaeria senegalensis
Neotestudina rosatii Pyrenochaeta mackinnonii
Pseudallescheria boydii Pyrenochaeta romeroi
---------------- Phlenodomus avramii
Table 2. Microorganisms Causing Actinomycetomas in Humans
Etiologic agent Grain
A madurae White, large, 1-5 mm in diameter
A pelletieri Red, hard, 1 mm in diameter
N brasiliensis White to yellow, multilobed, soft, < 0.5 mm in diameter
N asteroides Uncommon, white, soft, < 0.5 mm in diameter
Nocardia otitidiscaviarum White to yellow, lobed, < 0.5 mm in diameter
Nocardia transvalensis White to yellow, < 0.5 mm in diameter
Nocardia veterana[11] --
Nocardia mexicana[12] --
N harenae --
N takedensis --
Nocardiopsis dassonvillei White to yellow, < 0.5 mm in diameter
S somaliensis Yellow, hard, 2 mm in diameter
Streptomyces sudanensis Yellow, hard, 2 mm in diameter
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