Department of Orthopaedics: Moderators

DEPARTMENT OF
ORTHOPAEDICS
KMC,MANGLORE
DR.VINAY PAWAR
MODERATORS
DR.SURENDAR U. KAMATH
DR.HARSHVARDHAN
MADURA
FOOT
WHY WE SHOULD KNOW?

1.CAN BE CONFUSED WITH CHRONIC
OSTEOMYELITIS
2.CAN ITSELF CAUSE BONE INFECTION
3.ENDEMIC IN INDIA( ESPECIALLY
TAMIL NADU)
History
There have been

references of this
disease in Homers
Iliad
The clinical syndrome
was first described by
Gill-1842 in
Madurai,TN
Its fungal etiology
was established by
Carter-1868
Definition.
it is a chronic,painless,subcutaneous,
infection usually involving the feet,
characterized by formation of
localised leasions in form of
tumefactions and multiple draining
sinuses
Etiology..
Madura Foot- Actinomycosis

Mycetoma1.Bacterial
2.Fungal
3.S.Aureus- Botryomycosis
MYCETOMA
BACTERIAL
1.ACTINOMYCETES-A.Israelis,A.Bovis
2.NOCARDIA-N.Asteroides,N.Brazilienses
3.ACTINOMADURA-A.madurae,A.pelletreinie
4.STREPTOMYCES-S.somalienses
FUNGAL
1.Petrielldium Boydii
2.Madurella mycetomi
3.Acremonium spp
.
MODE OF INFECTION
CAN OCCUR ANYWHERE
The body parts affected.
most commonly -foot or lower leg.

The hand is the next most common
location.
The causative organism enters through
sites of local trauma (eg, cut on the hand,
foot splinter, local trauma related to
carrying soil-contaminated material).
Walking with bare feet
Clinical History
The earliest symp-painless subcutaneous

swelling..
Several years later- painless subcutaneous

nodule
After some years, massive swelling of the

area occurs, with induration, skin rupture,
and sinus tract formation.
Pain-secondary bacterial infection less

commonly, bone invasion.
Constitutional symptoms and signs are rare.
STAINING
H/E staining/Geimsa for detection of grains.

Actinomycetoma - Homogenously
eosinophilic
Eumycetoma - Brownish
The causal agent of each type of mycetoma
can be visualized better with the following:
Tissue Gram stain to detect fine, grampositive, branching filaments within the
actinomycetoma grain
Gomori methenamine silver or periodic acidSchiff stain to demonstrate the larger
hyphae of eumycetoma
White-to-yellow grains P boydii (S

apiospermum), Nocardia species, or A
madurae infection.
Yellow-to-brown grains S somaliensis
infection.
Black grains Streptomyces
paraguayensis, Madurella species, or
Leptosphaeria species infection.
Red-to-pink grains A pelletieri .
Culture
Lwenstein-Jensen actinomycetoma
blood agar for eumycetoma.
Serologic diagnosis
(1) immunodiffusion,
(2) counterimmunoelectrophoresis,
(3) enzyme-linked immunosorbent assay, or
(4) Western blot.
IMAGING STUDIES
Cortical
thinning
sunray appearance and a Codman
triangle.
Multiple lytic lesions large, few in
number, and with well-defined
margins in eumycetoma
small, numerous, and with ill-defined
margins in actinomycetoma.
Disuse osteoporosis may occur in late
mycetoma.
Radiological staging
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 row
Stage V - Horizontal spread along a single row
Stage VI - Multidirectional spread due to uncontrolled
infection
MRI D/D of the swelling and degree of bone and

soft tissue involvement.
-dot in circle sign: 2.5mm signals of high
intensity signals in low intensity foci-highly specific
for mycetoma
USG- 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.
eumycetoma, echoes are sharp,
actinomycetoma, echoes are fine and aggregated
and commonly settle at the provides a better
bottom of the cavities.
CT scan detail of changes than x-ray
Treatment..
Medical Care: Antibiotic or

antifungal treatment should be
attempted first and may need to be
combined with limited surgery
Surgery
ACTINOMYCETOMA
2 drugs in 5 weeks
cycle are used
Tmp/Smx-160/800mg
6thhourly PO
Amikacin-15mg/kg/d
IV/IM QID
Dapsone-10mg BD PO
-amikacin substituted by
streptomycin
-rifampicin in resistant
cases
EUMYCETOMA
-difficult to treat
-surgery is prefered for
localised leasions
-may respond partially
to Antifungals
Ketoconazole
(200mgbd)
Itraconazole (200mg
bd)
Amphotericin B
10 months
Deterrence/Prevention:
Educate patients to avoid activities that expose
them to agents of mycetoma
Complications:
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 .
THANK

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Department of Orthopaedics: Moderators

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DEPARTMENT OF

WHY WE SHOULD KNOW?

There have been

Madura Foot- Actinomycosis

CAN OCCUR ANYWHERE

The body parts affected.

most commonly -foot or lower leg.

The earliest symp-painless subcutaneous

Several years later- painless subcutaneous

After some years, massive swelling of the

Pain-secondary bacterial infection less

Constitutional symptoms and signs are rare.

H/E staining/Geimsa for detection of grains.

White-to-yellow grains P boydii (S

Stage 0 - Soft-tissue swelling without bone

MRI D/D of the swelling and degree of bone and

Medical Care: Antibiotic or

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