Tamer Ahmed EL-Sobky · John Fathy Haleem · Shady Samir Plain radiography and MRI of eumycetoma osteomyelitis of the calcaneus in a child Tamer Ahmed EL-Sobky · John Fathy Haleem · Shady Samir Division of Paediatric Orthopaedics, Orthopedic Surgery Department, Faculty of Medicine, Ain Shams University Egyptian Orthopaedic Association clinical meeting , 18-02-2016, Faculty of Medicine, Ain-Shams University, Cairo, Egypt. Correspondence should be addressed to Tamer Ahmed EL-Sobky; tamer.ahmed@med.asu.edu.eg tamersh@hotmail.com

Eumycetoma osteomyelitis Abstract Fungi are unusual causes of pedal osteomyelitis in children and adolescents. Eumycetoma is a chronic cutaneous and subcutaneous infection caused by various genera of fungi. A provisional diagnosis of foot mycetoma is made after clinical assessment. Clinical examination alone does not detect the spread of disease along the different tissue planes and bone. Other diagnostic tools as cytological, histopathological, serological, and culture techniques may be technically demanding. Imaging techniques such as magnetic resonance imaging (MRI) can aid in the early diagnosis of the lesion and can be used to determine the extent of lesions. We present the plain radiographic and MRI characteristics of an adolescent patient with extensive eumycetoma osteomyelitis of the calcaneus. The role of MRI in diagnosis, staging and planning of surgery is discussed. We concluded that MRI was useful in visualizing soft tissue involvement and bone invasion. MRI may be used besides other diagnostic tools to assist in reaching an accurate diagnosis. Key words: fungal osteomyelitis; radiography; bone infections; Madura foot 18/02/2016 Eumycetoma osteomyelitis

Eumycetoma osteomyelitis (b) Figure (1A, B): Radiographs of right foot. Oblique and lateral views. Note the soft tissue swelling, calcaneal disfigurement, rarefaction, subtalar collapse and cortical depression (white arrows) and cavitation (black arrows) (A) and (B). 18/02/2016 Eumycetoma osteomyelitis

Eumycetoma osteomyelitis (b) Figure (2A, B): Axial (A) and anteroposterior (B) views demonstrate huge cavitation (black arrows) and cortical disruption (white arrow). Note the marked bone sclerosis surrounding the cavities (B). 18/02/2016 Eumycetoma osteomyelitis

Eumycetoma osteomyelitis (b) Figure (3A, B,): MRI of the right foot. T1-weighted sagittal images show altered marrow signals seen almost totally replacing the marrow texture of the calcaneus and to a lesser extent the opposing postro-medial aspect of the talus (black arrow) eliciting an abnormal low signal (A). T2-weighted sagittal images show abnormal high signals replacing the marrow texture of the calcaneus. Note the multiple low-intensity lesions (black arrows) that represent a conglomerate of grains in the background of diffuse high-intensity inflammatory bone changes. These low intensity lesions are known as (dot in circle), (B) . 18/02/2016 Eumycetoma osteomyelitis

Eumycetoma osteomyelitis (b) Figure (4A, B): T2-weighted sagittal image. Note the low-intensity cavitary lesion of the posterior calcaneus (white arrow) that correlated well to a conglomerate of black grains noticed in the gross pathologic specimen of the calcaneus (A). T2-weighted coronal images show the (dot in circle) lesions in bone (black arrows) and soft tissues (white arrows) (B). 18/02/2016 Eumycetoma osteomyelitis

Eumycetoma osteomyelitis (b) Figure (5A, B): The (dot in circle) lesions are demonstrated (black arrows) in STIR sagittal images (A) and T2-weighted axial MRI (B). 18/02/2016 Eumycetoma osteomyelitis