eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Mycetoma: Differential Diagnoses & Workup

Author: Basilio J Anía, MD, Consultant in Internal Medicine, Associate Professor of Infectious Diseases, Department of Internal Medicine, Division of Infectious Diseases, Hospital Negrín & Universidad de Las Palmas de Gran Canaria, Spain
Coauthor(s): Margarita Asenjo, MD, Associate Professor, Department of Radiology, Medical School of the University of Las Palmas De Gran Canaria, Spain; Raphael J Kiel, MD, Associate Professor of Medicine, Wayne State University School of Medicine; Associate Program Director, Head of Infectious Disease Section, Department of Internal Medicine, Oakwood Hospital
Contributor Information and Disclosures

Updated: Aug 30, 2008

Differential Diagnoses

Aspergillosis

Other Problems to Be Considered

Botryomycosis
Thorn granuloma
Fibrolipoma
Neurofibroma
Necrotizing fasciitis
Cold abscess

Workup

Laboratory Studies

  • Staining
    • Hematoxylin-eosin staining of a biopsy sample allows for detection of mycetoma grains.
    • Process hematoxylin-eosin and May-Grünwald-Giemsa staining of a cytologic smear of a sample obtained via fine-needle aspiration. Mycetoma grains can be distinguished from artifacts and other organisms by the intimate relationship between the grain and neutrophils. The appearance of the grains is as follows:
      • Actinomycetoma - Homogenously eosinophilic with hematoxylin-eosin stain; blue in the center with pink filaments in the periphery with May-Grünwald-Giemsa stain
      • Eumycetoma - Brownish color with hematoxylin-eosin stain; black with a green tinge with May-Grünwald-Giemsa stain
    • The causal agent of each type of mycetoma can be visualized better with the following:
      • Tissue Gram stain to detect fine, gram-positive, branching filaments within the actinomycetoma grain
      • Gomori methenamine silver or periodic acid-Schiff stain to demonstrate the larger hyphae of eumycetoma
  • Evaluation of the characteristics of the associated granules suggests an initial differential diagnosis, as follows:
    • White-to-yellow grains indicate P boydii (S apiospermum), Nocardia species, or A madurae infection.
    • Yellow-to-brown grains indicate S somaliensis infection.
    • Black grains indicate Streptomyces paraguayensis, Madurella species, or Leptosphaeria species infection.
    • Red-to-pink grains indicate A pelletieri infection.
  • Culture the grains obtained from a deep wedge biopsy or a sample obtained via puncture and fine-needle aspiration. The primary isolation media used should be Löwenstein-Jensen for actinomycetoma or blood agar for eumycetoma.
  • Serologic diagnosis is available in a few centers and can be helpful in some cases for diagnosis or follow-up care during medical treatment. Antibodies can be determined via (1) immunodiffusion, (2) counterimmunoelectrophoresis, (3) enzyme-linked immunosorbent assay, or (4) Western blot.
  • Caution: Superficial samples of the draining sinuses are inadequate for culture because of frequent contamination with bacteria.

Imaging Studies

  • Bone radiography
    • Once mycetoma has invaded the bone, the following changes may be observed:
      • Cortical thinning is due to compression from the outside by the mycetoma.
      • Cortical hypertrophy or periosteal proliferation may present as a sunray appearance and a Codman triangle.
      • Multiple lytic lesions or cavities may be large and few in number with well-defined margins (eumycetoma) or small and numerous with ill-defined margins (actinomycetoma).
      • Disuse osteoporosis may occur in late stages mycetoma.
    • Bone involvement has been radiographically classified, as follows:
      • Stage 0 - Soft-tissue swelling without bone involvement
      • Stage I - Extrinsic pressure effects on the intact bones in the vicinity of an expanding granuloma
      • Stage II - Irritation of the bone surface without intraosseous invasion
      • Stage III - Cortical erosion and central cavitation
      • Stage IV - Longitudinal spreading along a single ray
      • Stage V - Horizontal spread along a single row
      • Stage VI - Multidirectional spread due to uncontrolled infection
  • MRI: This study helps with the differential diagnoses of the swelling and can provide a better assessment of the degree of bone and soft-tissue involvement. The dot-in-circle sign is a recently proposed MRI sign of mycetoma, which is likely to be highly specific.2
  • Ultrasonography
    • Single or multiple thick-walled cavities with hyperreflective echoes and no acoustic enhancement are always observed with mycetoma, whereas these features are not demonstrated in nonmycetoma swellings.
    • In eumycetoma, the hyperreflective echoes are sharp, corresponding to the grains in the lesion.
    • In actinomycetoma, the hyperreflective echoes are fine and closely aggregated and commonly settle at the bottom of the cavities.
  • CT scanning: This modality provides a better detail of changes than conventional radiography.

Procedures

Perform a deep wedge biopsy or puncture and fine-needle aspiration to obtain a grain sample.

Histologic Findings

Grains are surrounded closely and sometimes infiltrated by neutrophils. The causal agent can be stained better in biopsy samples with Gram stain (actinomycetoma) or Gomori methenamine silver or periodic acid-Schiff stains (eumycetoma).

Staging

Radiographic staging of bone involvement can be found in Imaging Studies.

More on Mycetoma

Overview: Mycetoma
Differential Diagnoses & Workup: Mycetoma
Treatment & Medication: Mycetoma
Follow-up: Mycetoma
Multimedia: Mycetoma
References
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Further Reading

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Keywords

mycetoma, maduromycosis, Madura foot, actinomycetoma, eumycetoma, bacterial mycetoma, fungal mycetoma, actinomycetes, pulmonary mycetoma, mycetoma grain, Pseudallescheria boydii, P boydii, Actinomadura madurae, A madurae, Actinomadura pelletieri, A pelletieri, Streptomyces somaliensis, S somaliensis, Nocardia, Scedosporium apiospermum, S apiospermum, Streptomyces paraguayensis, S paraguayensis, Leptosphaeria, Madurella mycetomatis, M mycetomatis

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Contributor Information and Disclosures

Author

Basilio J Anía, MD, Consultant in Internal Medicine, Associate Professor of Infectious Diseases, Department of Internal Medicine, Division of Infectious Diseases, Hospital Negrín & Universidad de Las Palmas de Gran Canaria, Spain
Disclosure: Nothing to disclose.

Coauthor(s)

Margarita Asenjo, MD, Associate Professor, Department of Radiology, Medical School of the University of Las Palmas De Gran Canaria, Spain
Disclosure: Nothing to disclose.

Raphael J Kiel, MD, Associate Professor of Medicine, Wayne State University School of Medicine; Associate Program Director, Head of Infectious Disease Section, Department of Internal Medicine, Oakwood Hospital
Raphael J Kiel, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Geriatrics Society, American Medical Association, and American Medical Informatics Association
Disclosure: Nothing to disclose.

Medical Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

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