Mycetoma of lower extremityS Sahariah, AK Sharma, VK Mittal, RVS Yadav
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 722604
Source of Support: None, Conflict of Interest: None
Ten cases of mycetoma of the lower extremity were seen and treated at the Postgraduate Institute of Medical Education & Research, Chandigarh, India, during the years 1973 to 1975. Six were treated by conservative method e.g. antibiotics, sulfonamides and immobilization of the part while remaining four were submitted t o surgery. Four out o f six from the first group had recurrence and has been put on second line of therapy. Recurrence occurred in only one case from the second group and he required an above knee amputation while the remaining three are free of disease and are well rehabilitated.
Mycetoma is a granulomatous lesion produced by micro-organisms (fungus) which penetrate through the skin, usually following trauma and subsequently grow in the subcutaneous tissues. The causative organism can invade subcutaneous tissues bones, ligaments and less commonly ten dons, muscles and nervous tissue.  Mycetoma has a world wide distribution but is common in tropics and subtropics. Maca tela-Ruiz  classified the mycetomas as (i) Actinomycotic mycetoma caused by aerobic actinomycetis, (ii) Maduramycotic mycetoma caused by true fungi and (iii) Actinomycosis caused by Actinomyces Israeli.
Zaias  et al mentioned that tumefaction and draining sinuses in any chronic infection should alert the clinician to the possibility of mycetoma. There is a lot of controversy about the treatment of mycetoma. Most of the authors mention the conservative line of management (Antibiotics and Dapsone) to be the treatment of choice. Lynch  is of the view that surgical excision, if possible, is the treatment of choice and it should be combined with antibiotics. As the micro-organisms are locked in fibrous tisuses and the blood supply to these areas are poor, antibiotics are to be given for longer period and in high doses.
We have encountered ten patients of mycetoma foot and leg at Nehru Hospital attached to The Post-gradute Institute of Medical Education and Research, Chandigarh, over a period of three years. These cases were treated both with antibiotics and surgery. The results are being presented.
The youngest patient was 23 years and the oldest was 65 years of age (mean age 43.5 years). There were eight males and two females [Table 1]. All patients presented with history of pain and swelling followed by discharging sinuses. The duration of symptoms varied from one and half years to four years, but the duration of the sinus formation was from 5 days to 3 months [Table 2].
Foot was the main site of involvement (9 cases) while the leg was involved in one. Out of the ten cases eight had multiple nodules with discharging sinuses and two had single nodule. Bony tenderness was present in five patients.
Various investigations done in these patients included ESR, skiagram of the chest and local part, smear and culture of the discharge and biopsy from the nodules [Table 3]. ESR was raised in all the cases indicating the presence of chronic infection. Skiagram of the chest was normal in nine cases while tubercular lesion was detected in one. X-ray of the local part showed osteolytic areas with sclerosis in five patients and all these patients had bony tenderness. The remaining five patients had no bony involvement. Smear made from the discharge showed fungus in six cases whereas it could be cultured in only three cases. Biopsies from the nodules were done in 9 cases and were positive in all.
Six patients were treated with long term broad spectrum antibiotics, sulphonamides and immobilisation. Out of them five had changes in the bones and no surgical excision was possible. Though the bones were spared in the sixth case, the involvement was so extensive that chemotherapy alone was considered a better choice. Rest four patients were treated by the combination of surgery and chemotherapy. In two patients, surgical excision and skin grafting was done with good results whereas in one case only curettage was possible. In the fourth patient, a below knee amputation was done but subsequently he had recurrence of the disease at the amputation stump for which above knee amputation was done at a later date [Table 4].
Out of the six cases treated conservatively four had recurrence of the disease and have been put on heavy doses of antibiotics again. Probably all these patients will need amputation of the involved limb subsequently. The Patients with excision and skin grafting and curettage have been followed up from six months to two years and are doing well without any disability
Mycetoma, though not a fatal disease, can produce many disabilities in late stages. Various types of drugs like broad spectrum antibiotics, sulphonamides, dapsone, trimethoprim and sulpharnethoxazole combination have been used in the treatment of mycetoma. These drugs are to be given in large doses and for a longer period. Various authors have reported good results with this line of management. Cockshott and Ranking treated 18 patients with broad spectrum antibiotics and dapsone combined with immobilisation of the part. Eight patients responded well to the therapy. Zaias  et al advocated a trial of medical treatment combined with conservative surgical intervention. Rogers and Muller  treated 3 patients with only dapsone and had good results. Absence of bony involvement contributed greatly to the good response to dapsone therapy. Lynch  suggested surgical intervention as the treatment of choice whether it is radical or conservative. He presented six hundred and twenty cases of mycetoma and out of these one hundred and sixty four patients ended in amputation.
He reported a reccurrence rate of 25 per cent within one to three years and attributed the recurrence to the difficulty at operation to indentify the limits of spread of the mycetoma.
We have treated six patients with chemotherapy alone and 4 with surgery and chemotherapy. In 5 of the 6 cases with chemotherapy, there was bony involvement and so they were put on antibiotics combined with immobilisation. Four patients were treated with surgery. Excision with skin grafting was done in two patients where the disease was limited to the subcutaneous tissue only. In one patient only curettage was done along with antibiotic cover. All these three patients are doing well. In the fourth patient, an amputation was done due to recurrence of the disease and involvement of the bones secondarily. This patient has been lost to follow up.
The indication for surgery has been either the disease process is limited to soft tissues alone and no bony involvement or the resistant cases with bony involvement not responding to repeated long term conservative therapy. Most of the resistant cases with bony involvement will end up in amputation. Recurrence was seen in 4 of the 6 patients from chemotherapy group and one of the 4 from combination group.
Though no definite conclusion can be drawn regarding the choice of treatment in mycetoma from this small series, we found conservative surgical excision along with chemotherapy gives the best result in selected patients.
[Table 1], [Table 2], [Table 3], [Table 4]