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CASE REPORT Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 2  |  Page : 125-126
Multiple foot sinuses due to schizomycetes


1 Department of Orthopaedics, St. John's Medical College Hospital, Bangalore, India
2 Department of Surgery, St. John’s Medical College Hospital, Bangalore, India

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How to cite this article:
Amaravati RS, Angamuthu N. Multiple foot sinuses due to schizomycetes. Indian J Orthop 2005;39:125-6

How to cite this URL:
Amaravati RS, Angamuthu N. Multiple foot sinuses due to schizomycetes. Indian J Orthop [serial online] 2005 [cited 2019 Jul 19];39:125-6. Available from: http://www.ijoonline.com/text.asp?2005/39/2/125/36791

   Introduction Top


Multiple sinuses of the foot though infrequent in the surgical practice are known for its chronicity and diagnostic dilemmas. It is imperative for the clinician to carefully examine and evaluate for a mycetoma. Therapeutic outcome in mycetoma depends on the accuracy of diagnosis, appropriate antibiotics and long-term compliance [1] . A patient who developed multiple foot sinuses following trauma is discussed. This report highlights the chronicity, diagnostic difficulties and management problems.


   Case report Top


A 38-year-old male potter presented to us with a wound in the left foot of a year's duration following an injury with a wooden log. Six months earlier he had undergone a surgical excision but the lesions recurred. He was anemic; left foot showed a diffuse swelling and multiple sinuses discharging turbid fluid [Figure - 1]a. A clinical diagnosis of osteomyelitis or mycetoma was made. X-ray foot showed osteoporosis with multiple lytic lesions in the tarsal bones and lower third of tibia [Figure - 1]b. Smears for AFB, bacterial and fungal cultures were negative. Definite granules were not seen. A deep tissue biopsy was planned but patient refused. I.V Penicillin 20 lakh units 6 hourly was given for a month. Streptomycin 750 mg I.M (once a day x 3 months; then alternate days for 3 months) with oral Co-trimoxazole twice a day was administered for 6 months. Activity of sinuses significantly decreased at end of four weeks. In view of the classical clinical findings and therapeutic response a presumptive diagnosis of Actinomycosis was made. At the end of 3 months the sinuses had healed, discharge stopped, oedema reduced [Figure - 1]c and audiogram revealed normal hearing. Patient had pain on weight bearing for which a below knee walking cast was applied for two months. After 7 months of therapy, streptomycin was stopped; co-trimoxazole was given for two months. At the latest follow up patient was fine.


   Discussion Top


Mycetoma is a chronic localized granulomatous inflammatory lesion common in the tropics and sub-tropics[1] . Multiple sinuses, soft tissue swelling and discharge of coloured granules characterize a mycetoma foot. [2] Chronic sinuses discharging granules are caused by (1) Eumycetes (true fungi), (2) Schizomycetes, which includes i. Actinomycosis (aerobic higher filamentous bacteriae) and ii. Botryomycosis (bacterial infection)[1],[2] .

Actinomycosis is often caused by Actinomadura or Nocardia species wherein it gains entry after penetrating trauma (splinter, gravel or thorn prick) [1],[2],[3] . Young males are commonly affected and 75% of the lesions occur in the lower limbs. [1] The disease slowly progresses from a nodule to multiple sinuses discharging coloured granules. Involvement of bone is late following dermal and soft tissue spread. Botryomycosis (a misnomer), a chronic suppurative infection is caused by bacteria involving skin or viscera [4] . This rare condition mimics a deep mycotic infection and is often caused by Staphylococcus or Pseudomonas species of bacteria. The feet and hands are commonly affected and penetrating trauma may be a predisposing factor. It usually presents as a nodule, sinus or ulcer, which is initially localized.

The diagnosis of actinomycosis is based on clinical findings, demonstration of characteristic granules and culture of the organism from a deep tissue biopsy [1],[2],[3] . Immunological studies (counter immuno electrophoresis and ELISA) are also used. Botryomycosis is diagnosed based on a positive gram's stain and culture; negative fungal cultures and demonstration of the characteristic botryomycotic granules at histopathology from a deep biopsy [4] . In endemic areas, subcutaneous swelling with sinuses should be considered as mycetoma unless proved otherwise [1] . The differential diagnosis includes chronic osteomyelitis, tuberculosis and chronic abscesses [1],[2] .

Mycetoma caused by true fungi are less responsive to medical therapy than actinomycosis or botryomycosis [2],[3] . Actinomycosis usually responds to a combination of streptomycin and co-trimoxazole. In non-responders dapsone or rifampicin is added [1] . Amikacin and amoxicillin with clavulanic acid have been recently reported to be useful [5] . In botryomycosis a prolonged course of a single drug (based on sensitivity report) is used initially [4] . Drainage of abscesses, conservative reductive surgery, and surgical excision helps to shorten the duration of therapy. In endemic areas resistance to commonly used drugs is a problem [5] . The optimal duration of medical therapy is still not clear [3] .

Chronic bacterial or deep fungal infection of foot presents with multiple sinuses. The basic tenets of management include clinical examination, high index of suspicion, isolation and culture of the organism. Prolonged antibiotic therapy usually yields a favorable response. Surgery is reserved for diagnostic biopsy, failure of medical treatment, persistent or recurrent disease. Repeated improper surgical procedures without antibiotic therapy have to be avoided as this deters the patients from undergoing further therapy as in our cases.

 
   References Top

1.Mahgoub ES. Mycetoma. In: Gurrent RL, Walker DH, Weller PF (eds), Tropical infectious Diseases: Principles, pathogens and practice. 1st ed. New York: Churchill Livingstone. 2000; 616-20.  Back to cited text no. 1    
2.Singh H. Mycetoma. In: Gupta RL (ed), Recent advances in surgery. New Delhi; Jaypee Brothers. 1987: 308-24.  Back to cited text no. 2    
3.Wortman PD. Treatment of a Nocardia brasiliensis Mycetoma with sulfa-methoxazole and trimethoprim, amikacin and amoxicillin and clavulanate, Arch Dermatol. 1993; 129: 564-7.  Back to cited text no. 3  [PUBMED]  
4.Bonifaz A, Carrasco F. Botryomycosis. Int J Dermatol. 1996; 35: 381-8.  Back to cited text no. 4    
5.Gomez A, Saul A, Bonifaz A, et al. Amoxicillin and clavulanic acid in treatment of actinomycetoma. Int J Dermatol. 1993; 32: 218-20.  Back to cited text no. 5    

Top
Correspondence Address:
Rajkumar S Amaravati
Department of Orthopaedics, St. John's Medical College Hospital, Bangalore-560034
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36791

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]

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[Pubmed] | [DOI]



 

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