1. CASE PRESENTATION What is the diagnosis?? 04/09/2015 Dr. J. Jagoda – Consultant Rheumatologist/DGH Gampaha Dr A. P. J. Cooray – Senior Registrar- Rheumatology/RRH Ragama

2. Mr. P : 37 year old driver - 2003 Mild discomfort and a lump in the anterior aspect of the knee ▫No other joint swelling ▫No fever ▫No rash ▫No recent history of an illness ▫No trauma

3. Visits a Consultant Physician Some blood tests were done ▫?ESR/FBC – were said to be normal Reassured and given painkillers Lump regresses leaving behind an indurated area of skin and another two appear at different locations ▫Ignored by the patient ▫Not painful ▫No discharge ▫No systemic illness ▫Heal with scarring

4. 2005 – He goes to the Surgeon Lump reappears at a different location ▫Discharges grainy material ▫Previous scars also start discharging ▫FBC – Thrombocytosis, ESR 39mm ▫X-Ray: Soft tissue swelling with periosteal reaction ▫US scan : 4.5/2.0 cm cystic lesion superficial to the Tibia. Impression is that of a chronic abscess

5. Superficial nodule is excised - 2005 Histopathology report ; fibro connective tissue shows foci of eosonophillic crystalline material surrounded by neutrophills and pallisades of histiocytes. The stoma shows sheets of inflammatory cells gout Conclusion; The features are compatible with gout # #Uric acid – 2.6mg/dl

6. Severe knee pain with joint swelling - 2009 Fluid aspirated out from KJ ▫Full report and culture sent ▫Mantoux test negative ▫Chest X ray – nothing to suggest TB

8. Pain relief is given – feels well till 2013 ( Still has discharging nodules) Tries ayurvedic treatment ▫Severe pain in KJ with swelling and fever ▫Goes to a Consultant Rheumatologist  WBC 11.6 * Neutrophill predominent, Platelets 691000  ESR 130mm/CRP 96mg/dl  Aspirated out  MRI done  Arthroscopic synovial biopsy arranged

9. MRI report

10. Pigmented villonodular synovitis A benign proliferative disorder of the synovium Clinical pattern ▫Isolated tenosynovitis (Tenosynovial giant cell tumour) ▫Diffused form ▫Localized form

11. MRI – characteristic appearance: Low signal intensity lesion in T1/T2 sequences

12. Histopathology – synovial proliferation with foam cells & haemosiderin laden giant cells

14. Antibiotics for 2 weeks and pain relief ROM is now diminished Multiple scar marks on his left knee New subcutaneous nodules keep appearing But no other joint involvement He is feeling well i.e no fever, no night sweats, no loss of weight

16. Back to our patient - 2014 Multiple discharging nodules with stiffness of the knee ▫ESR – 52mm ▫Normal FBC ▫FNAC of nodule : suppurative inflammation ▫Synovial biopsy repeated ▫Trial of ATT considered

17. What can it be? Bone and joint TB Gout Rheumatoid arthritis Tumour Some other rare cause

18. BIOPSY REPORT 2014

19. Mycetoma Chronic granulomatous subcutaneous infection Aetiology ▫Actinomycetes – A.Pelletieri, A.Madurae, Nocardia sps ▫Fungi – P.boydii, M.Mycetomatosis

20. Clinical phases Painless subcutaneous swelling ▫Indurated area Subcutaneous nodule Spread to contiguous tissue ▫Sinus tracts – sulphur granules

21. Diagnosis Imaging ▫Radiography/CT ▫US scan ▫MRI Laboratory diagnosis ▫Histopathology ▫Culture

22. Features 1.Cortical thickening 2.Periosteal reaction 3.Lytic lesions

23. Features 1. Dot in circle sign

24. Histopathology FNAC or wedge biopsy Synovial biopsy ▫Gram stain/Geimsa stain

25. Identifying the causative organism Actinomycetoma Eumycetoma Filamentous bacteria Gram positive 01 micrometer or less Periphery is basophillic and the center is eosonophillic Large grains True fungai with hyphae and many chlamydophores Gram negative 2-4 micrometers Large grain is 5mm or more

26. Management ActinomycetomaEumycetoma Co-trimaxozole Dapsone and Streptomycin Rifampicin Gentamycin Penicillin Itraconazole

27. Do we finally have a diagnosis ? Is it eumycetoma or actinomycetoma

28. Thank you Acknowledgements ▫Dr C.S.P Sosai – Consultant Histopathologist ▫Dr P. Rathnayake – Consultant Histopathologist ▫Dr M. Kothalawela – Consultant Microbiologist