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

Mycetoma

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

Introduction

Background

Mycetoma is a chronic subcutaneous infection caused by actinomycetes or fungi. This infection results in a granulomatous inflammatory response in the deep dermis and subcutaneous tissue, which can extend to the underlying bone. Mycetoma is characterized by the formation of grains containing aggregates of the causative organisms that may be discharged onto the skin surface through multiple sinuses. Mycetoma was first described in the mid 1800s and initially named Madura foot, after the region of Madura in India where the disease was first identified.

Mycetoma caused by microaerophilic actinomycetes is termed actinomycetoma, and mycetoma caused by true fungi is called eumycetoma. These conditions are to be differentiated from actinomycosis, which is an endogenous suppurative infection caused by Actinomyces israelii or other species of Actinomyces or related bacteria, affecting the cervical-facial, thoracic, and pelvic sites (the latter is usually associated with the use of intrauterine devices). The branching bacteria that cause actinomycosis are non–acid-fast anaerobic or microaerophilic bacteria. These bacteria are smaller than 1 µm in diameter, smaller than eumycotic agents. On the other hand, the agents that cause actinomycetoma are always aerobic and are sometimes weakly acid-fast.

More than 20 species of fungi and bacteria can cause mycetoma. The ratio of mycetoma cases caused by bacteria (actinomycetoma) to those caused by true fungi (eumycetoma) is 197:67.

Pathophysiology

The body parts affected most commonly in persons with mycetoma include the foot or lower leg, with infection of the dorsal aspect of the forefoot being typical. The hand is the next most common location; however, mycetoma lesions can occur anywhere on the body. Lesions on the chest and back are frequently caused by Nocardia species, whereas lesions on the head and neck are usually caused by Streptomyces somaliensis.

The causative organism enters through sites of local trauma (eg, cut on the hand, foot splinter, local trauma related to carrying soil-contaminated material). A neutrophilic response initially occurs, which may be followed by a granulomatous reaction. Spread occurs through skin facial planes and can involve the bone. Hematogenous or lymphatic spread is uncommon.

Frequency

United States

Mycetoma is rare in the United States. Some cases are due to increasing international travel. Rarely, mycetoma is acquired on US soil.1 Pseudallescheria boydii (Scedosporium apiospermum) is the most common cause of this condition.

International

Mycetoma is endemic in Africa, from Sudan and Somalia through Mauritania and Senegal. Other endemic countries include Mexico and India; however, mycetoma can also be found in natives of areas of Central and South America and the Middle or Far East between latitudes 15°S and 30°N. In Sudanese hospitals, at least 300-400 patients are diagnosed with mycetoma every year.

Mortality/Morbidity

Mycetoma causes disfigurement but is rarely fatal in the absence of skull involvement. The lesions are painless and slowly progressive; however, secondary bacterial infection or bone expansion may cause pain. In advanced cases, deformities or ankylosis and their corresponding disabilities can appear. Patients who are immunocompromised or who have undergone transplantation can develop invasive infection.

Race

Mycetoma has no apparent racial predilection.

Sex

Mycetoma has a male-to-female ratio of 183:81.

Age

Mycetoma is most common in persons aged 20-50 years.

Clinical

History

  • The earliest sign of mycetoma is a painless subcutaneous swelling. Some patients have a history of a penetrating injury at that site.
  • Several years later, a painless subcutaneous nodule is observed. After some years, massive swelling of the area occurs, with induration, skin rupture, and sinus tract formation.
  • As the infection spreads to contiguous body parts, old sinuses close and new ones open.
  • Nearly 20% of patients with mycetoma experience associated pain, usually due to secondary bacterial infection or, less commonly, bone invasion.
  • Constitutional symptoms and signs of mycetoma are rare.
  • Patients may report a deep itching sensation.

Physical

  • Irrespective of the causal agent, the appearance of the mycetoma lesion is consistent, as follows:
    • Initially, subcutaneous swelling is present.
    • In a later phase, a subcutaneous nodule develops.
    • Eventually, massive swelling with induration, rupture of the skin, and formation of sinus tracts occur.
  • In general, eumycetoma is more circumscribed and progresses slower than actinomycetoma.
  • Regional lymphadenopathy is unusual; when it does occur, it is due to one of the following:
    • Lymphatic spread of mycetoma to regional nodes occurs in only 1-3% of affected patients.
    • Secondary bacterial infection or a local immunologic reaction may enlarge the regional lymph nodes.
  • Lymphatic obstruction and fibrosis can cause lymphedema and erythema.
  • Pulmonary mycetoma has been found to develop and progress more rapidly in individuals infected with HIV.

Causes

  • Mycetoma occurs most often in farmers, shepherds, Bedouins, nomads, and people living in rural areas.
  • Frequent exposure to penetrating wounds by thorns or splinters is a risk factor.
  • Actinomycetoma can be caused by the following:
    • Actinomadura madurae
    • Actinomadura pelletieri
    • S somaliensis
    • Nocardia species
  • Eumycetoma is caused primarily by P boydii (S apiospermum).

More on Mycetoma

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