1. IS MYCETOMA ENDMIC IN EGYPT ?By
Prof.Dr. M. Taha

2. Mycetoma is subcutanous infectious granulomatous chronic disease which may spread to adjacent skin and bone.
Generally mycetoma characterized by :
- Tumefaction
- Draining sinuses
- Grains

3. Gill 1842 was the first who describe the disease during his work in Madura,india Carter 1874 named the disease mycetoma and proved its mycotic nature . The first cases in Africa was described in Sengal in 1894 and in Sudan The division of the disease into separate categories dependent on fungal etiology (eumycetoma)and actinomycotic etiology (actinomycetoma) was first suggested by Pinory 1913.

4. Mycetoma occurs unevenly worldwide but is endemic in tropical and sub-tropical as Sudan,Somalia, Singal India,Yemen,Mexico,Venezuela
Colombia and Argentina in region
Known as mycetoma belt

5. In Egypt there is no avialable literature (to my knowledge) about mycetoma except those wrote by El Mofty et al 1956 and El Zawahry 1967 Recently tens of mycetoma cases were recieved in my private lab for mycological examination which means that there is more cases of mycetoma in Egypt

6. Causes of mycetoma 1- Actinomadura madurae 3- Nocadia brasiliensis
Actinomycetoma
Caused by species of areobic Actinomycetes as :
1- Actinomadura madurae
3- Nocadia brasiliensis
4- Nocardia asteroides
5- Streptomyces somaliensis

7. Causes of mycetoma Eumycetoma : caused by species of fungi as:
1-Madurella mycetomatis
2-Madurella grisea
3-Leptosphaeria senegalensis
4-Pseudallescheria boydii
5-Acremonium (A.faciform, A.kiliense, A.recifei)
6-Aspergillus spp. (A. nidulans A. flavus)

8. The main cause of mycetoma in Egypt according to 27 cases examined during 3 years ( ) were : Actinomadura madurae (4) Nocardia asteroides (1) Madurella mycetomatis (17) Madurella grisea (1) Four cases had grains but the organism could not be isolated

9. Clinical presentation
Most patients seek care after long periods of disease
The first sign noticed is the presence of a painless swelling,vesicles small abscesses or boils
Fistula with drainig of viscous or purulent exudate and granules(grains) usually predominant

10. The lesion grow slowly with darker aspect and firmer consistency than surrounding skin
The lesion become painful at the late stage due to the involvment of nerves
Process involve from 3 month to years
About 70 % of mycetoma involve the foot while hands ,knee ,legs and head are less common

11. % No. of cases Affected organs 66.66 18 Foot 18.51 5 Hand 7.40 Leg2
Leg
3.70 1
Knee
Head and neck

12. Male predominance is a constant findings
Male predominance is a constant findings. 24 male and 3 female were recorded in the examined 27 cases, from them 23 were egyptian,3 from Yemen and one from Somalia. All examined cases affected the adult between y and most of them are agricultural workers

13. Eumycetoma grow slowly with less destructive less suppurative, less inflammatory with more swelling and late bone affection than actinomycetoma

14. Actinomycetoma caused by N.madurae

15. Actinmycetoma caused by Nocadia asteroides

16. Eumycetoma caused by M.mycetomatis

17. Eumycetoma caused by M.mycetomatis

18. Eumycetoma caused by M. mycetomatis

19. Black grain eumycetoma with darker aspect than surrounding skin

20. Eumycetoma caused by M.mycetomatis

21. Knee mycetoma caused by M.mycetomatis

22. Eumycetoma showing purulunt exudate and black grains

23. Diagnosis 1-Macro and micro examination of grains
Collection of grains done by covering draining sinus opening with sterile pads for 8-12 h . It examined for color ,size and consistency which differ accordinge the causative agent. Grains examined microscopicaly after crushed between two slides with KOH or stained by gram

24. Main characters of grains according organisms
Microscopy
Consistency
Size
Color
M.mycetomatis
Broad compact colored hyphae with vesicles in some
hard
0.7- 5
Black
M.grisea
compact broad hyphae weakly pigmented in centre
soft
L.senegaliensis
Loose netork of hyphae in centre and vesicel in peripheral
0.5- 2
Acremonium sp
Allescheria boydii
Network of hyaline hyphae
0.5-1
white
A.madurae
Thin hyphae in network
0.5- 5
White
A.pelletiere
thin mycelial filaments
Red
N.brasiliensis
thin hyphae
>0.5
Y.white
N.asteroids
network of thin hyphae
0.15-2
S.somaliensis
0.5-2
Yellow

25. 2- Culture grains as well as exudate are cultured on suitable media
2- Culture grains as well as exudate are cultured on suitable media . In case of black grains Sabouraud’s dextrose agar and dermatophyte test medium is suitable while for white grains sabouraud’s or malt extrat agar as well as blood agar are used. Incubation time and degree of temperature is differ from bacterial isolates or fungi .

26. 3- Radiological findings CT and MRI typically demonstrated bone lesion earlier than X rays .A dot in circle sign demonstrated by MRI is consider specific for mycetoma. Ultrasonic imaging : hyperreflective echos and cavities can differentiate between mycetoma and non-mycetoma lesions

27. 4 - Histopathology Infected tissue should be sectioned and stained with H &E, PAS and GMS. Brown-Brenn stained tissue preparation in actinomycetoma revealed gram positive filaments 5- Serology 6- Molecular

28. Grains of Actinomadura madurae

29. White grains of M.madurae crushed and stained by Gram

30. Cultur characters of actinomycetes isolated from examined cases
Actinomadura madurae : slow growing on SDA reach 1.5 cm in weeks . Colonies are moist ,mucoid with pink colour. Old culture showed fragmentation of hyphae
Nocardia asteroides : grow quickly on SDA produce pale yellow to orange colonies with cerebriform appearance .Microscopic of colonies showed delicate branching hyphae with bowlling form

31. Colonies of N.asteroides on SDA

32. Black grains from mycetoma caused by M.mycetomatis

33. Black grains

34. Microscopic of black grains after KOH preparation

35. Characters of Madurella spp. isolated from eumycetoma
M.mycetomatis
Grow on SDA and DTM in days with brown diffuse pigment . Colonies are velvety white then become greyish to dark olive. Microscopically usually sterile showed hyphae and few chlamydospores

36. Madurela grisea
Similar to M.mycetomatis but rapid growing white to grey colonies can not grow at 37c and oval conidia are present
M.madurae assimilate lactose and not sucrose while M.grisea assimilate sucrose and not lactose

37. M.mycetomatis on SDA showing diffuse brown pigment

38. M.Maycetomatis on SDA showing velvety greyish colonies with diffuse pigment

39. Treatment in mycetoma a) actinomycetoma
In vitro study with isolated bacteria revealed the sensitivity of A.madurae to Trimethoprime-sulphamethoxazole, Amoxicillin clavulanic acid and amikacin while N.asteroides was sensitive to ciprofloxacin and erythromycin.

40. Treatment of actinomycetic mycetoma usually done with combination of streptomycin and dapsone .
Amikacin 15 mg/kg /d in combination with Trimethoprime-sulphamethoxazole 8-40 mg/kg/d for 5 five weeks are used
in cycles cycles were recommanded

41. b) eumycetoma
In vitro study Madurella mycetomas revealed the sensitivity to itraconazole.
Treatment of eumycetoma usually done by
- Ketoconazole mg- 800 mg daily for 9 m
- Itraconazole mg daily
- Voriconazole mg x2 /day for 3 months

42. Thank You