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Mycetoma – An unusual site
Images in surgery In this section we will feature outstanding photographs of clinical materials. These will be selected for their educational value, message, or possibly rarity. The images will be accompanied by brief case reports (limit 2 typed pages, 3 references). Our readers are invited to submit items for consideration.
Mycetoma – An unusual site Naresh Soni, MS, Ashwini Gupta, MS, and N. S. Shekhawat, MS, Rajasthan, India
From the Upgraded Department of Surgery, S.M.S. Medical College and Hospital, Jaipur-302004, Rajasthan, India
A 33-year-old man was admitted with the complaint of multiple sinuses in the left gluteal region. A small swelling had developed in this Accepted for publication Aug 21, 1999. Surgery 2000;127:709-10. Reprint requests: Dr Naresh Kumar Soni, H No 515, Bordi Ka Rasta, Kishan Pole Bazar, Jaipur – 302003, Rajasthan, India. Copyright © 2000 by Mosby, Inc. 0039-6060/2000/$12.00 + 0
11/60/102605
doi:10.1067/msy.2000.102605
site 25 years earlier. It was excised, but the wound had healed with nodule formation. The area remained unchanged for more than 10 years without causing any problem to the patient, until it started discharging black granules. It was reexcised. The lesion again recurred 10 years later in the form of multiple nodules. After 5 years, these nodules evolved into multiple discharging sinuses. The patient was treated with various antibiotics and with diaminodiphenyl sulfone (Dapsone) (100 mg, twice daily) and antifungal
Fig 1. Mycetoma involving gluteal region. SURGERY 709
710 Soni, Gupta, and Shekhawat
Surgery June 2000
Fig 2. Photomicrograph of lesion showing fungal colonies.
drugs ketoconazole (200 mg, twice a day), and fluconazole (150 mg, once a day) for 1 year without response. He was at this time referred to S.M.S. Medical College in Jaipur, India. Fig 1 shows the lesion on the left buttock. A bacterial culture showed that the pus discharging from the sinuses was sterile. A skin biopsy confirmed the clinical suspicion of mycetoma (Fig 2). The entire lesion was excised down to normal subcutaneous tissues with a 2.5-cm radial margin. The defect was covered by split-thickness skin graft. Cotrimoxazole (960 mg, twice daily) and diaminodiphenyl sulfone (100 mg, twice daily) were administered postoperatively, and the wound healed without complication. There has been no recurrence at 2 years. DISCUSSION Mycetoma is a chronic granulomatous lesion that may begin as a skin papule, nodule, or abscess but develops as a suppurative infection of subcutaneous tissues. The causative organisms are true fungi (Eumycetoma) or higher bacteria, namely
aerobic actinomycetes (Actinomycetoma).1 It is prevalent mainly in tropical and subtropical countries. The disease was first discovered in Madurai, India, and the foot was the most common site of infection; hence, it came to be known as “Madura foot.” Though Madura mycosis has been found in other parts of the body, including the ear, orbit, testis, mandible, air sinuses and perianal area,2,3 the location described in the present case has not to our knowledge been noted in the world literature. Considering the village background of the patient, the source of infection may well have been a thorn prick while he was squatting to defecate. The diagnosis should be confirmed, as in this instance, by histopathologic examination. Medical treatment alone or inadequate surgery is ineffective. Radical excision with adjuvant antibiotic chemotherapy is necessary to cure the disease. REFERENCES 1. Gonzalez-Ochoa A. Mycetoma. In: Canizares O, editor. Clinical tropical dermatology. Oxford: Blackwell Scientific; 1975. p. 24-9. 2. Singh H. Mycetoma in India. Indian J Surg 1979;41:577-97. 3. Fahal AH, Hassan MA. Mycetoma. Br J Surg 1992;79:1138-41.
Mycetoma – An unusual site Naresh Soni, MS, Ashwini Gupta, MS, and N. S. Shekhawat, MS, Rajasthan, India
From the Upgraded Department of Surgery, S.M.S. Medical College and Hospital, Jaipur-302004, Rajasthan, India
A 33-year-old man was admitted with the complaint of multiple sinuses in the left gluteal region. A small swelling had developed in this Accepted for publication Aug 21, 1999. Surgery 2000;127:709-10. Reprint requests: Dr Naresh Kumar Soni, H No 515, Bordi Ka Rasta, Kishan Pole Bazar, Jaipur – 302003, Rajasthan, India. Copyright © 2000 by Mosby, Inc. 0039-6060/2000/$12.00 + 0
11/60/102605
doi:10.1067/msy.2000.102605
site 25 years earlier. It was excised, but the wound had healed with nodule formation. The area remained unchanged for more than 10 years without causing any problem to the patient, until it started discharging black granules. It was reexcised. The lesion again recurred 10 years later in the form of multiple nodules. After 5 years, these nodules evolved into multiple discharging sinuses. The patient was treated with various antibiotics and with diaminodiphenyl sulfone (Dapsone) (100 mg, twice daily) and antifungal
Fig 1. Mycetoma involving gluteal region. SURGERY 709
710 Soni, Gupta, and Shekhawat
Surgery June 2000
Fig 2. Photomicrograph of lesion showing fungal colonies.
drugs ketoconazole (200 mg, twice a day), and fluconazole (150 mg, once a day) for 1 year without response. He was at this time referred to S.M.S. Medical College in Jaipur, India. Fig 1 shows the lesion on the left buttock. A bacterial culture showed that the pus discharging from the sinuses was sterile. A skin biopsy confirmed the clinical suspicion of mycetoma (Fig 2). The entire lesion was excised down to normal subcutaneous tissues with a 2.5-cm radial margin. The defect was covered by split-thickness skin graft. Cotrimoxazole (960 mg, twice daily) and diaminodiphenyl sulfone (100 mg, twice daily) were administered postoperatively, and the wound healed without complication. There has been no recurrence at 2 years. DISCUSSION Mycetoma is a chronic granulomatous lesion that may begin as a skin papule, nodule, or abscess but develops as a suppurative infection of subcutaneous tissues. The causative organisms are true fungi (Eumycetoma) or higher bacteria, namely
aerobic actinomycetes (Actinomycetoma).1 It is prevalent mainly in tropical and subtropical countries. The disease was first discovered in Madurai, India, and the foot was the most common site of infection; hence, it came to be known as “Madura foot.” Though Madura mycosis has been found in other parts of the body, including the ear, orbit, testis, mandible, air sinuses and perianal area,2,3 the location described in the present case has not to our knowledge been noted in the world literature. Considering the village background of the patient, the source of infection may well have been a thorn prick while he was squatting to defecate. The diagnosis should be confirmed, as in this instance, by histopathologic examination. Medical treatment alone or inadequate surgery is ineffective. Radical excision with adjuvant antibiotic chemotherapy is necessary to cure the disease. REFERENCES 1. Gonzalez-Ochoa A. Mycetoma. In: Canizares O, editor. Clinical tropical dermatology. Oxford: Blackwell Scientific; 1975. p. 24-9. 2. Singh H. Mycetoma in India. Indian J Surg 1979;41:577-97. 3. Fahal AH, Hassan MA. Mycetoma. Br J Surg 1992;79:1138-41.