AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Mycetoma is a chronic subcutaneous infection caused by actinomycetes or fungi. This infection results in a granulomatous inflammatory response in the deep dermis and subcutaneous tissue, which can extend to the underlying bone. Mycetoma is characterized by the formation of grains containing aggregates of the causative organisms that may be discharged onto the skin surface through multiple sinuses. This disease was described first in the mid 1800s and initially named Madura foot, after the region of Madura in India where it first was identified.

Actinomycetomas are mycetomas caused by microaerophilic actinomycetes, and mycetomas caused by true fungi are called eumycetomas. These conditions are to be differentiated from actinomycosis. Actinomycosis is an endogenous suppurative infection caused by Actinomyces israelii or other species of Actinomyces or related bacteria, affecting the cervical-facial, thoracic, and pelvic sites (the latter usually is associated with the use of intrauterine devices). The branching bacteria causing actinomycosis are non–acid-fast anaerobic or microaerophilic bacteria. These bacteria are less than 1 micrometer in diameter and are small compared to the larger diameter of eumycotic agents. On the other hand, the agents of actinomycetoma always are aerobic and sometimes are weakly acid-fast.

More than 20 species of fungi and bacteria can cause mycetoma. The ratio of mycetomas that are caused by bacteria (actinomycetoma) to those that are caused by true fungi (eumycetoma) is 197:67.

Pathophysiology

The body parts affected most commonly are the foot or lower leg, with infection of the dorsal aspect of the forefoot being typical. The hand is the next most common location; however, lesions can occur anywhere on the body. Lesions on the chest and back frequently are caused by Nocardia species, whereas lesions on the head and neck usually are caused by Streptomyces somaliensis.

The causative organism enters through sites of local trauma (eg, cut on the hand, foot splinter, local trauma related to carrying soil-contaminated material). A neutrophilic response initially occurs, which may be followed by a granulomatous reaction. Spread occurs through skin facial planes and can involve the bone. Hematogenous or lymphatic spread is uncommon.

Frequency

United States

Mycetoma is rare. Pseudallescheria boydii (Scedosporium apiospermum) is the most common cause of this condition.

International

This condition is endemic in Africa, from Sudan and Somalia through Mauritania and Senegal. Other endemic countries are Mexico and India; however, the disease also can be found in natives of areas of Central and South America and the Middle or Far East between latitudes 15°S and 30°N. In Sudan, at least 300-400 patients are diagnosed in hospitals every year.

Mortality/Morbidity

The disease causes disfigurement but rarely is fatal; however, when the skull is involved, a risk to life exists. The lesions are painless and slowly progressive; however, pain may occur when secondary bacterial infection or bone expansion occurs. In advanced cases, deformities or ankylosis and their corresponding disabilities can appear. Patients who are immunocompromised or who have undergone transplantation can develop invasive infection.

Race

No particular risk based on race has been described.

Sex

The male-to-female ratio is 183:81.

Age

This condition most frequently occurs in patients aged 20-50 years.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• The earliest sign is a painless subcutaneous swelling. Some patients have a history of a penetrating injury at that site.
• Several years later, a painless subcutaneous nodule is observed. After some years, massive swelling of the area occurs, with induration, skin rupture, and sinus tract formation.
• As the infection spreads to contiguous body parts, old sinuses close and new ones open.
• Pain occurs in nearly 20% of patients and usually is due to secondary bacterial infection or, less commonly, bone invasion.
• Constitutional symptoms and signs are rare.
• Patients may complain of a deep itching sensation.

Physical

• Irrespective of the causal agent, the appearance of the lesion is similar and consists of the following:
• • Initially, subcutaneous swelling is present.
  • In a later phase, a subcutaneous nodule develops.
  • Eventually, massive swelling with induration, rupture of the skin, and formation of sinus tracts occur.
• In general, eumycetomas are more circumscribed and progress slower than actinomycetomas.
• Regional lymphadenopathy is unusual, but when it does occur, it is due to one of the following:
• • Lymphatic spread of mycetoma to regional nodes occurs in only 1-3% of patients.
  • Secondary bacterial infection or local immunological reaction can cause enlargement of regional lymph nodes.
• Lymphatic obstruction and fibrosis can cause lymphedema and erythema.
• Pulmonary mycetoma has been found to develop and progress more rapidly in individuals infected with HIV.

Causes

• This condition most often occurs in farmers, shepherds, Bedouins, nomads, or people living in rural areas.
• Frequent exposure to penetrating wounds by thorns or splinters is a risk factor.
• Actinomycetoma can be caused by the following:
• • Actinomadura madurae
  • Actinomadura pelletieri
  • S somaliensis
  • Nocardia species
• Eumycetoma is caused primarily by P boydii (S apiospermum).

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Botryomycosis
Thorn granuloma
Fibrolipoma
Neurofibroma
Necrotizing fasciitis
Cold abscess

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Staining
• • Hematoxylin-eosin staining of a biopsy sample allows for detection of grains.
  • Process hematoxylin-eosin and May-Grünwald-Giemsa staining of a cytologic smear of a sample obtained by fine-needle aspiration. Mycetoma grains can be distinguished from artifacts and other organisms by the intimate relationship between the grain and neutrophils. The appearance of the grains is determined as follows:
  • • Actinomycetoma - Homogenously eosinophilic with hematoxylin-eosin stain; blue in the center with pink filaments in the periphery with May-Grünwald-Giemsa stain
    • Eumycetoma - Brownish color with hematoxylin-eosin stain; black with a green tinge with May-Grünwald-Giemsa stain
  • The causal agent of each type of mycetoma can be visualized better with the following:
  • • Tissue Gram stain to detect fine, gram-positive, branching filaments within the actinomycetoma grain
    • Gomori methenamine silver or periodic acid-Schiff stain to demonstrate the larger hyphae of eumycetoma
• Evaluation of the characteristics of the associated granules suggests an initial differential diagnosis, as follows:
• • White-to-yellow grains are indicative of P boydii (S apiospermum), Nocardia species, or A madurae infection.
  • Yellow-to-brown grains are indicative of S somaliensis infection.
  • Black grains are indicative of Streptomyces paraguayensis, Madurella species, or Leptosphaeria species infection.
  • Red-to-pink grains are indicative of A pelletieri infection.
• Culture the grains obtained from a deep-seated wedge biopsy or a sample obtained by puncture and fine-needle aspiration. The primary isolation media used should be Löwenstein-Jensen for actinomycetoma or blood agar for eumycetoma.
• Serologic diagnosis is available in a few centers and can be helpful with some patients for diagnosis or follow-up care during medical treatment. Antibodies can be determined by means of (1) immunodiffusion, (2) counterimmunoelectrophoresis, (3) enzyme-linked immunosorbent assay, or (4) Western blot.
• Caution: Superficial samples of the draining sinuses are inadequate for culture due to frequent contamination with bacteria.

Imaging Studies

• Bone radiograph
• • Once mycetoma has invaded the bone, several changes can be observed, as follows:
  • • Cortical thinning is due to compression from the outside by the mycetoma.
    • Cortical hypertrophy or periosteal proliferation may present as a sunray appearance and a Codman triangle.
    • Multiple lytic lesions or cavities may be large, few in number, and with well-defined margins in eumycetoma or small, numerous, and with ill-defined margins in actinomycetoma.
    • Disuse osteoporosis may occur in late mycetoma.
  • Bone involvement has been radiographically classified, as follows:
  • • Stage 0 - Soft-tissue swelling without bone involvement
    • Stage I - Extrinsic pressure effects on the intact bones in the vicinity of an expanding granuloma
    • Stage II - Irritation of the bone surface without intraosseous invasion
    • Stage III - Cortical erosion and central cavitation
    • Stage IV - Longitudinal spreading along a single ray
    • Stage V - Horizontal spread along a single row
    • Stage VI - Multidirectional spread due to uncontrolled infection
• MRI helps with the differential diagnosis of the swelling and can provide a better assessment of the degree of bone and soft tissue involvement.
• Ultrasonography: Single or multiple thick-walled cavities with hyperreflective echoes and no acoustic enhancement always are observed with mycetoma, whereas these features are not demonstrated in nonmycetoma swellings.
• • In eumycetoma, the hyperreflective echoes are sharp, corresponding to the grains in the lesion.
  • In actinomycetoma, the hyperreflective echoes are fine and closely aggregated and commonly settle at the bottom of the cavities.
• CT scan provides a better detail of changes than those observed with conventional radiographs.

Procedures

• Perform a deep-seated wedge biopsy or puncture and fine-needle aspiration to obtain a grain sample.

Histologic Findings

Grains are surrounded closely and sometimes infiltrated by neutrophils. The causal agent can be stained better in biopsy samples with Gram stain for actinomycetoma and with Gomori methenamine silver or periodic acid-Schiff stains for eumycetoma.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Antibiotic or antifungal treatment should be attempted first and may need to be combined with limited surgery.

External beam radiotherapy in doses ranging from 3.5-14 Gy has been considered successful treatment in a few selected cases.

Surgical Care

Surgery is recommended for localized lesions that can be excised completely without residual disability. Surgical reduction of large lesions can improve the patient's response to medical treatment; however, partial surgical resection without subsequent use of appropriate antimicrobial or antifungal agents is prone to failure.

Consultations

Consultation with specialists in infectious disease or tropical medicine is advised in areas of the world in which these conditions are unfamiliar.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Actinomycetoma is a bacterial infection that can respond to antibiotics if treatment is administered early in the course of the disease. A combination of 2 drugs in 5-week cycles is used. If needed, the cycles can be repeated once or twice. The following agents have been used in combination: trimethoprim-sulfamethoxazole (TMP-SMZ), dapsone (diaminodiphenylsulfone), and streptomycin sulfate. Amikacin can be substituted for streptomycin but usually is kept as a second-line drug because of its cost. Rifampin has been used as a second-line drug in resistant cases. In one case report, a patient required salvage therapy with amikacin and imipenem for 6 months.

Eumycetoma may respond partially to antifungal agents, although surgical therapy is preferred if the disease is localized. Madurella mycetomatis may respond to ketoconazole (200 mg bid). P boydii (S apiospermum) should be primarily treated with voriconazole, although it may also respond to itraconazole. Other agents of eumycetoma may respond intermittently to itraconazole (200 mg bid) or amphotericin B. The minimum treatment duration is 10 months. Voriconazole is the drug of choice for invasive infections caused by agents of eumycetoma in patients who are immunocompromised.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of a clinical setting suggestive of actinomycetoma.

Drug Name	Amikacin (Amikin)
Description	Irreversibly binds to 30S subunit of bacterial ribosomes, blocks recognition step in protein synthesis, and causes growth inhibition. Should be given continuously for 3 wk. Although somewhat expensive, it usually is active against the bacteria causing actinomycetoma. Use the patient's IBW for dosage calculation.
Adult Dose	15 mg/kg/d IV/IM qd or divided bid; not to exceed 1.5 g/d regardless of higher BW
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration with other aminoglycosides, penicillins, cephalosporins, and amphotericin B increases nephrotoxicity; enhances effects of neuromuscular blocking agents; causes respiratory depression; irreversible hearing loss may occur with coadministration of loop diuretics
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Not intended for long-term therapy; caution in patients with renal failure (not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission; risk of nephrotoxicity and ototoxicity

Drug Name	Dapsone (Avlosulfon)
Description	Bactericidal and bacteriostatic against mycobacteria. Mechanism of action is similar to sulfonamides where competitive antagonists of PABA prevent formation of folic acid, inhibiting bacterial growth. Lowest-cost regimen. Change to TMP-SMZ if no response occurs after 1 mo.
Adult Dose	100 mg PO bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; G-6-PD deficiency
Interactions	May inhibit anti-inflammatory effects of clofazimine; hematologic reactions may increase with folic acid antagonists, eg, pyrimethamine (monitor for agranulocytosis during the second and third mo of therapy); probenecid increases toxicity; TMP may increase toxicity of both drugs; due to increase in renal clearance, levels may decrease significantly when administered concurrently with rifampin
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Perform weekly blood counts for the first mo; then, perform WBC counts monthly for 6 mo and semiannually thereafter; discontinue if significant reduction in platelets, leukocytes, or hematopoiesis is observed; caution in methemoglobin reductase deficiency, G-6-PD deficiency (patients receiving >200 mg/d), or hemoglobin M due to high risk for hemolysis and Heinz body formation; caution in patients exposed to other agents or conditions (eg, infection, diabetic ketosis) capable of producing hemolysis; peripheral neuropathy can occur (rare); phototoxicity may occur when exposed to UV light

Drug Name	Rifampin (Rimactane, Rifadin)
Description	For use in combination with at least 1 other agent. Inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur.
Adult Dose	10 mg/kg/d PO qd
Pediatric Dose	10 mg/kg/d PO; not to exceed 600 mg/d
Contraindications	Documented hypersensitivity
Interactions	Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, dapsone, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue 1 or both agents if alterations in LFTs occur)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May cause abnormal liver function, drug fever, flu syndrome, or hematological cytopenias; obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur

Drug Name	Imipenem and cilastatin (Primaxin)
Description	For treatment of multiple-organism infections in which other agents do not have wide spectrum coverage or are contraindicated due to potential for toxicity.
Adult Dose	Base initial dose on severity of infection and administer in equally divided doses; 0.5-1 g IV q6h; not to exceed 3-4 g/d Alternate dose: 500-750 mg IM q12h
Pediatric Dose	<12 years: Not established; 15-25 mg/kg/dose IV q6h suggested for > 3 mo Fully susceptible organisms: Not to exceed 2 g/d Infections with moderately susceptible organisms: Not to exceed 4 g/d
Contraindications	Documented hypersensitivity
Interactions	Coadministration with cyclosporine may increase adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Adjust dose in renal insufficiency; avoid use in children <12 y

Drug Category: Antifungal agents

In combination with surgical therapy, antifungal agents may help to attain partial response in cases of eumycetoma.

Drug Name	Itraconazole (Sporanox)
Description	Fungistatic activity. Synthetic triazole antifungal agent that slows fungal cell growth by inhibiting cytochrome P-450–dependent synthesis of ergosterol, a vital component of fungal cell membranes.
Adult Dose	200 mg/d PO; not to exceed 400 mg/d; increase in 100-mg increments if no improvement (administer >200 mg/d in divided doses) 200 mg IV bid for 4 doses, followed by 200 mg/d
Pediatric Dose	Not established; suggested dose of 100 mg/d
Contraindications	Documented hypersensitivity; coadministration with cisapride may cause adverse cardiovascular effects (possibly death)
Interactions	Antacids may reduce absorption of itraconazole; edema may occur with coadministration of calcium channel blockers (eg, amlodipine, nifedipine); hypoglycemia may occur with sulfonylureas; may increase tacrolimus and cyclosporine plasma concentrations when high doses are used; rhabdomyolysis may occur with coadministration of HMG-CoA reductase inhibitors (ie, lovastatin, simvastatin); coadministration with cisapride can cause cardiac rhythm abnormalities and death; may increase digoxin levels; coadministration may increase plasma levels of midazolam or triazolam; phenytoin and rifampin may reduce levels (phenytoin metabolism may be altered)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hepatic insufficiencies

Drug Name	Amphotericin B (Fungizone)
Description	Polyene antibiotic produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal cell membrane, causing intracellular components to leak with subsequent fungal cell death. Conventional formulation (complexed with deoxycholate) has a poor tolerability profile. Liposomal amphotericin B incorporates the drug into small unilamellar liposomes; this formulation retains the antifungal activity with less hypokalemia, anemia and infusion reactions, and far less nephrotoxicity than the conventional formulation. Although the acquisition cost of liposomal amphotericin B is considerably higher than that of the conventional formulation, when adverse effects are considered, the calculated total costs of treatment for fungal infections are not clearly different.
Adult Dose	3-5 mg/kg/d IV of liposomal amphotericin B over approximately 120 min
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antineoplastic agents may enhance the potential of amphotericin B for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; the risk of renal toxicity is increased with cyclosporine
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Monitor renal function, serum electrolytes (eg, magnesium, potassium), liver function, CBC, and hemoglobin concentrations; resume therapy at lowest level (eg, 0.25 mg/kg) when therapy is interrupted for more than 7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in patients with neutropenia who are receiving leukocyte transfusions (separate time of amphotericin infusion from time of leukocyte transfusion); fever and chills are not uncommon after first few administrations; rare acute reactions may include hypotension, bronchospasm, arrhythmias, and shock

Drug Name	Voriconazole (VFEND)
Description	Used for primary treatment of invasive aspergillosis and salvage treatment of Fusarium species or S apiospermum infections. A triazole antifungal agent that inhibits fungal cytochrome P450-mediated 14 alpha-lanosterol demethylation, which is essential in fungal ergosterol biosynthesis.
Adult Dose	Loading dose: 6 mg/kg IV q12h infused over 2 h for 2 doses Maintenance: 4 mg/kg IV q12h infused over 2 h; switch to 200 mg PO q12h when able to tolerate; may increase to 300 mg PO q12h if inadequate response <40 kg: Average maintenance dose is 100 mg PO q12h (may increase to 150 mg PO q12h)
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; CrCl <50 mL/min (decreased excretion of IV vehicle) if administering IV; coadministration with rifampin, rifabutin, carbamazepine, barbiturates, sirolimus, pimozide, quinidine, cisapride, and ergot alkaloids
Interactions	CYP450 2C19 (highest affinity), 2C9, and 3A4 (minor) substrate and inhibitor; CYP450 inducers (eg, rifampin) have shown to decrease steady state peak plasma levels by up to 93%; may increase serum levels of drugs metabolized by CYP450 2C19 or 2C9, of which some are contraindicated (eg, sirolimus, pimozide, quinidine, cisapride, ergot alkaloids); other drugs may need more frequent monitoring (eg, cyclosporine, tacrolimus, warfarin, HMG-CoA inhibitors, benzodiazepines, calcium channel blockers)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Decrease maintenance dose in hepatic dysfunction; common adverse effects include visual disturbances, fever, rash, vomiting, nausea, diarrhea, headache, sepsis, peripheral edema, abdominal pain, rash (including Stevens-Johnson syndrome and phototoxicity), and respiratory disorder; rare cases of severe hepatotoxicity reported; administer PO dosage form 1 h ac or pc

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

• Maintain medical treatment and follow-up care for at least 10 months.

Deterrence/Prevention

• Educate patients to avoid activities that expose them to agents of mycetoma. Instruct patients to avoid carrying sticks and thorny branches that have had contact with the soil.

Complications

• Complications result mainly from toxicity due to prolonged administration of antimicrobial or antifungal drugs.
• Amputation may result from neglected chronic infections.

Prognosis

• Prognosis is good with prompt diagnosis and treatment. Although prognosis for survival is good, amputations or ankylosis can lessen the quality of life.
• In late stages, response to treatment is limited.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Mistaking actinomycosis for actinomycetoma is possible.
• Performing incomplete surgery as the sole therapy for this disease can lead to recurrence and a poor cosmetic outcome.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Actinomycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years.
	View Full Size Image
Media type:  Photo

Media file 2:  Frontal view of actinomycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years.
	View Full Size Image
Media type:  Photo

Media file 3:  MRI coronal section of actinomycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years. On this T1-potentiated image, a large heterogenous mass surrounds the cranium. Bone invasion can be observed only in the area of the zygomatic fossa.
	View Full Size Image
Media type:  MRI

Media file 4:  MRI with coronal view of actinomycetoma in a 47-year-old shepherd from Mauritania who had a painless progressive swelling of the face for more than 20 years. The actinomycetoma mass invades the left parapharyngeal space and almost reaches the lumen of the pharynx.
	View Full Size Image
Media type:  MRI

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Abd El Bagi ME. New radiographic classification of bone involvement in pedal mycetoma. AJR Am J Roentgenol. Mar 2003;180(3):665-8. [Medline].
• Ahmed AO, van Leeuwen W, Fahal A, et al. Mycetoma caused by Madurella mycetomatis: a neglected infectious burden. Lancet Infect Dis. Sep 2004;4(9):566-74. [Medline].
• Akhtar MA, Latief PA. Actinomycetoma pedis. Postgrad Med J. Nov 1999;75(889):671. [Medline].
• Bapat KC, Pandit AA. Actinomycotic mycetoma. Report of a case with diagnosis by fine needle aspiration. Acta Cytol. Nov-Dec 1991;35(6):770-2. [Medline].
• Baril L, Boiron P, Manceron V, et al. Refractory craniofacial actinomycetoma due to Streptomyces somaliensis that required salvage therapy with amikacin and imipenem. Clin Infect Dis. Aug 1999;29(2):460-1. [Medline].
• Boiron P, Locci R, Goodfellow M, et al. Nocardia, nocardiosis and mycetoma. Med Mycol. 1998;36 Suppl 1:26-37. [Medline].
• Bouza E, Munoz P. Invasive infections caused by Blastoschizomyces capitatus and Scedosporium spp. Clin Microbiol Infect. Mar 2004;10 Suppl 1:76-85. [Medline].
• Campagnaro EL, Woodside KJ, Early MG, et al. Disseminated Pseudallescheria boydii (Scedosporium apiospermum) infection in a renal transplant patient. Transpl Infect Dis. Dec 2002;4(4):207-11. [Medline].
• Chaveiro MA, Vieira R, Cardoso J, Afonso A. Cutaneous infection due to Scedosporium apiospermum in an immunosuppressed patient. J Eur Acad Dermatol Venereol. Jan 2003;17(1):47-9. [Medline].
• Chavez G, Estrada R, Bonifaz A. Perianal actinomycetoma experience of 20 cases. Int J Dermatol. Aug 2002;41(8):491-3. [Medline].
• Coukell AJ, Brogden RN. Liposomal amphotericin B. Therapeutic use in the management of fungal infections and visceral leishmaniasis. Drugs. Apr 1998;55(4):585-612. [Medline].
• Develoux M, Dieng MT, Kane A, Ndiaye B. [Management of mycetoma in West-Africa]. Bull Soc Pathol Exot. Jan 2003;96(5):376-82. [Medline].
• Dieng MT, Sy MH, Diop BM, et al. [Mycetoma: 130 cases]. Ann Dermatol Venereol. Jan 2003;130(1 Pt 1):16-9. [Medline].
• EL Hag IA, Fahal AH, Gasim ET. Fine needle aspiration cytology of mycetoma. Acta Cytol. May-Jun 1996;40(3):461-4. [Medline].
• Fahal AH, Sheik HE, Homeida MM, et al. Ultrasonographic imaging of mycetoma. Br J Surg. Aug 1997;84(8):1120-2. [Medline].
• Fahal AH, Hassan MA. Mycetoma. Br J Surg. Nov 1992;79(11):1138-41. [Medline].
• Fahal AH. Mycetoma: a thorn in the flesh. Trans R Soc Trop Med Hyg. Jan 2004;98(1):3-11. [Medline].
• Falkson C, Sur R, Pacella J. External beam radiotherapy: a treatment option for massive haemoptysis caused by mycetoma. Clin Oncol (R Coll Radiol). Jun 2002;14(3):233-5. [Medline].
• Fletcher CL, Moore MK, Hay RJ. Eumycetoma due to Madurella mycetomatis acquired in Jamaica. Br J Dermatol. Dec 2001;145(6):1018-21. [Medline].
• Greenberg AK, Knapp J, Rom WN, Addrizzo-Harris DJ. Clinical presentation of pulmonary mycetoma in HIV-infected patients. Chest. Sep 2002;122(3):886-92. [Medline].
• Hay RJ, Moore M. Mycology. In: Champion RH, Wilkinson DS, Ebling FJG, Breathnach SM, eds. Rook/Wilkinson/Ebling Textbook of Dermatology. Vol 2. 6th ed. Oxford, UK: Blackwell Science; 1998:. 1277-376.
• Hay RJ. Fungal infections. In: Cook GC, ed. Manson's Tropical Diseases. 20th ed. London, UK: WB Saunders; 1996:. 1047-74.
• Khatri ML, Al-Halali HM, Fouad Khalid M, et al. Mycetoma in Yemen: clinicoepidemiologic and histopathologic study. Int J Dermatol. Sep 2002;41(9):586-93. [Medline].
• Lichon V, Khachemoune A. Mycetoma : a review. Am J Clin Dermatol. 2006;7(5):315-21.
• Mahgoub ES. Medical management of mycetoma. Bull World Health Organ. 1976;54(3):303-10. [Medline].
• Mahgoub ES. Agents of mycetoma. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. Vol 2. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000:. 2702-6.
• Maiti PK, Ray A, Bandyopadhyay S. Epidemiological aspects of mycetoma from a retrospective study of 264 cases in West Bengal. Trop Med Int Health. Sep 2002;7(9):788-92. [Medline].
• Mellinghoff IK, Winston DJ, Mukwaya G, Schiller GJ. Treatment of Scedosporium apiospermum brain abscesses with posaconazole. Clin Infect Dis. Jun 15 2002;34(12):1648-50. [Medline].
• Mendez-Tovar LJ, Mondragon-Gonzalez R, Manzano-Gayosso P, et al. [Immunoglobulins in patients with Nocardia brasiliensis actinomycetoma]. Rev Argent Microbiol. Oct-Dec 2004;36(4):174-8. [Medline].
• O''Bryan TA. Pseudallescheriasis in the 21st century. Expert Rev Anti Infect Ther. Oct 2005;3(5):765-73.
• Poncio Mendes R, Negroni R, Bonifaz A, Pappagianis D. New aspects of some endemic mycoses. Med Mycol. 2000;38 Suppl 1:237-41. [Medline].
• Queiroz-Telles F, McGinnis MR, Salkin I, Graybill JR. Subcutaneous mycoses. Infect Dis Clin North Am. Mar 2003;17(1):59-85, viii. [Medline].
• Ramam M, Garg T, D''Souza P, et al. A two-step schedule for the treatment of actinomycotic mycetomas. Acta Derm Venereol. Sep-Oct 2000;80(5):378-80. [Medline].
• Saag MS. Mycetoma. In: Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. 21st ed. Philadelphia, Pa: WB Saunders; 2000:. 1885-7.
• Saarinen KA, Lestringant GG, Czechowski J, Frossard PM. Cutaneous nocardiosis of the chest wall and pleura--10-year consequences of a hand actinomycetoma. Dermatology. 2001;202(2):131-3. [Medline].
• Sharma N, Mendiratta V, Sharma RC, et al. Pulse therapy with amikacin and dapsone for the treatment of actinomycotic foot: a case report. J Dermatol. Oct 2003;30(10):742-7. [Medline].

Article Last Updated: Jan 8, 2007