MYCETOMA IN CHILDREN Bonifaz A, Ibarra G, Saúl A, Carrasco E. Title MYCETOMA IN CHILDREN Bonifaz A, Ibarra G, Saúl A, Carrasco E. Dermatology & Micology Department General Hospital of Mexico Hospital Infantil de Mexico

Introduction MYCETOMA IN CHILDREN Chronic infection Based on its etiology: eumycetoma (true fungae) actinomycetoma (filamentous actinomycetes) Clinically characterized by swelling, sinuses and alteration of affected region Mycetoma are uncommon in children. Only few reports* * Aceves Ortega R. Deep mycosis in children. Mod Probl Paediatr 1975;17: 228-241. Welsh O. Mycetoma in children. Mod Probl Paediatr 1975; 17:248-253.

Introduction MYCETOMA IN CHILDREN Occurs in well-defined geographic areas. Between the tropics Actinomycetoma is more frequent in subtropical areas (Mexico, Venezuela) Eumycetoma: predominates in Africa and India

Mexican multi-center study that included 2,105 cases.* Background MYCETOMA IN CHILDREN Frequency: Mexican multi-center study that included 2,105 cases.* 78 cases were under 15 years: 3.7% 11 cases were under 10 years: 0.5% In our study: 15/334: 4.5% *López-Martínez R, Méndez-Tovar LJ, Lavalle P, Welsh O, Saúl A, Macotela-Ruiz E. Epidemiología del micetoma en México: estudio de 2105 casos. Gac Med Mex 1992; 128: 477-481.

Factors to development mycetoma: Background MYCETOMA IN CHILDREN Factors to development mycetoma: Factors Patient’s condition Inoculum Hormonal

Mycetoma is an occupational disease… Background MYCETOMA IN CHILDREN Mycetoma is an occupational disease… Traumas Farm labors More frequent in boys, maybe help more in farm works

Sub-tropical area: actinomycetoma Nocardia spp Ecology MYCETOMA IN CHILDREN Sub-tropical area: actinomycetoma Nocardia spp Tropical-Senegalese climate: Eumycetoma. Madurella mycetomatis y Pseudoallescheria boydii

Two clinical features: MYCETOMA IN CHILDREN Two clinical features: Classical form: swelling, sinuses and alteration of affected region Milder presentation (mini-mycetoma): 1 or 2 sinuses (no-swelling). Clinical diagnosis is more difficult Seldom involvement of bones and viscera

Age MYCETOMA IN CHILDREN Mean 11.2 years Range: 6-15 years

Gender MYCETOMA IN CHILDREN 12 boys 80% 3 girls 20%

Clinical location MYCETOMA IN CHILDREN

Predisposing factors MYCETOMA IN CHILDREN

A 10 year old boy Evolution: 2 years Dermatosis localized to the right leg. Pruritus Direct exam: Nocardia granules N. brasiliensis

A 12 year old girl Evolution: 1 year Dermatosis localized to the left shoulder. Pruritus Direct exam: Nocardia granules N. brasiliensis

A 15 years old boy Evolution: 3 years Localized to the left foot. Pain Direct exam: eumycetic black granules M. mycetomatis

A 11 years old girl Evolution: 8 months Dermatosis localized to the left arm. Pruritus Direct exam: Nocardia granules N. brasiliensis

A 10 years old boy Evolution: 4 months Dermatosis localized to the left leg. Pruritus & pain Direct exam: Nocardia granules N. asteroides

A 14 years old boy Evolution: 1 year Milking worker Dermatosis localized to the hand right. Biopsy: A. madurae granules Actinomadura madurae

A 15 years old boy Evolution: 6 months Dermatosis localized in torax. Pain Direct exam: Nocardia granules N. brasiliensis

A 6 years old girl Evolution: 2 years Dermatosis localized to the left shoulder. Pruritus Direct exam: Nocardia granules N. brasiliensis

A 17 year old boy Evolution: 4 years Dermatosis localized to the torax. Pruritus & pain Direct exam: Nocardia granules N. brasiliensis

A 13 years old boy Evolution: 4 years Dermatosis localized to the torax. Pain Direct exam: Nocardia granules No culture

Direct examination (KOH, lugol & ISS) Grains or granules Lab Diagnosis MYCETOMA IN CHILDREN Direct examination (KOH, lugol & ISS) Grains or granules Culture (Sabouraud, PDA, etc.) Identifying microorganisms Biopsy

Etiology MYCETOMA IN CHILDREN

Amoxicilin/clavulanate Eumycetoma: Griseofulvin Treatment MYCETOMA IN CHILDREN Actinomycetoma: TMP-SMX + DDS Amikacin Amoxicilin/clavulanate Eumycetoma: Griseofulvin Ketoconazole, itraconazole

MYCETOMA IN CHILDREN Shortest: 8 months Longest: 2.5 years Treatment response MYCETOMA IN CHILDREN Shortest: 8 months Longest: 2.5 years Mean: 1.3 years

TMS-SMX + DDS

TMS-SMX + DDS

TMS-SMX + DDS

Summary I Comment: Successful treatment depends on 3 conditions: the etiologic agent, the extent and depth of the mycetoma, and the patient condition Good prognosis - 14 years-old - Healthy N. brasiliensis

Summary II Comment: Successful treatment depends on 3 conditions: the etiologic agent, the extent and depth of the mycetoma, and the patient condition Bad prognosis - Deficient GI absorption - Osteolysis M. mycetomatis

Mycetomas are exceptional in children Conclusions MYCETOMA IN CHILDREN Mycetomas are exceptional in children In Mexico actinomycetomas are more frequent than eumycetomas Clinical and diagnosis is simple Treatment response is better for actinomycetomas than eumycetomas Bonifaz A, Saúl A, Ibarra G, Rosales A, Araiza J, Méndez-Tovar LJ. Micetoma en niños y adolescentes. Monogr Dermatol 2006; 19: 17-23 Bonifaz A, Ibarra G, Saúl A, Paredes-Solis V, Carrasco-Gerard E, Fierro-Arias L. Mycetoma in children. Experience with 15 cases. Pediatr Infect Dis J 2007; 26: 50-52

Thank you very much for your attention Final MYCETOMA IN CHILDREN Thank you very much for your attention