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Madura Foot

  1. Madura foot is chronic infection of skin and underlying tissues caused by both bacteria (actinomycetomas) and fungi (eumycetomas).
  2. It is characterized by indolent tumefaction of the affected area, multiple sinus tracts and granules that contain agents.
  3. It was first described in Indian town of Madura.
  4. Often it occur in people who work in rural areas usually in farmers. Hunter gatherer populations and feel labourers where they are exposed to acacia trees or cactus thorns that contain the etiologic agents that normally live as saprophytes. In cities it is found in people who are victims of road accident who have incurred traumatic inoculation of the agents.
  5. Sub-tropical regions and African continent have the highest prevalence.
  6. Infection enters through sites of local trauma e.g. cut or splinter causing granulomatous reaction. Spread occurs through skin facial planes and can involve the bone.
  7. Two third involve the foot but may involve hand back or shoulder.
  8. It follows slow chronic course over many years with pain less swelling and intermittent discharge of pus.
  9. There may be a deep itching sensation.
  10. Small hard painless nodules.
  11. Pain may be due to secondary bacterial infection or bone invasion.
  12. After long course massive swelling of the area occurs with induration skin rupture and sinus tract formation.
  1. Lab studies: Direct microscopy.
    1. Serosanguineous fluid containing the granules examined using 10% KOH and parker ink or calcofluor white mounts. Tissue sections stained using H&E, PAS digest.
    2. Actinomycotic grains contain very fine filaments. Fungal grains contain short hyphae (branched filaments) that are often swollen
    3. DNA sequencing has been used for identification in difficult case. Sequencing analysis of the small ribosomal subunit gene or sequencing of conserved genes such as HSP65.
    4. X-rays for evidence of bone involvement.
      1. Cortical thinning due to compression from outside by mycetoma.
      2. Multiple lytic lesions or cavities
      3. Osteoporosis in lead cases.
    5. MRI for better assessment of degree of bone and soft tissue involvement.
    6. DOT in CIRCLE SIGN: recently purposed MRI sign of mycetoma is highly specific. It is seen in soft tissues.
  2. Treatment:
    1. Actinomycetomas usually respond better to medical treatment than eumycetomas
    2. Therapy is suggested for1-2 years (or greater) for complete eradication, unless adverse effects warrant cessation of medication.
    3. The current treatment of actinomycetoma is trimethoprim- sulfamethoxazole 7.5-40mg/kg daily in 3 oral doses for several months or years.
    4. Combination therapy with trimethoprim-sulfamethoxazole, dapsone and streptomycin, Amikacin, Minocycline, Penicillin has been used. Rifampin has been used in resistant cases.

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