CHAPTER XXVIII

MYCETOMA

GENERAL REMARKS

Various destructive processes of different parts of the body, but more commonly of the foot, which are caused by invasion and growth of fungi are generally designated mycetomas. Chalmers and Archibald have studied these conditions most carefully and have grouped most of them under maduro-mycoses and actinomycoses. The mycetomas are characterized by the presence of fungi in the form of grains composed of hyphae, and at times chlamydospores, imbedded in a matrix. These grains may be imbedded in the tissues or present in the discharge from the sinuses. Eosinophile bodies are usually present. The maduro-mycoses have grains with large segmented mycelial filaments, possessing well defined walls and usually chlamydospores. We have white or yellow, black and red ones according to the colour of the grains. The actinomycoses have very fine nonsegmented mycelial filaments with ill-defined walls and no chlamydospores. We have black, yellow and red grain actinomycoses. In addition to the mycetomas we recognize paramycetomas and pseudomycetomas, the former of which show fungi which do not show any grain formation and the latter failing to have present either fungi or eosinophile bodies. The pseudomycetomas are associated only by reason of clinical resemblance.

HISTORY AND GEOGRAPHICAL DISTRIBUTION

=History.=—The disease was first described by Kaempfer about 200 years ago, but at that time was often confused with elephantiasis. The first exact clinical description of the disease, with its pathology, in which was noted the fungus nature of the granules given off in the discharges from the sinuses, was that of Vandyke Carter, whose studies were carried on from forty to fifty years ago.

=Geographical Distribution.=—The name Madura foot takes its origin from the great prevalence of the affection about Madura, in the Madras Presidency of India. It is less frequent in other parts of India. It also occurs in Ceylon. The disease is rather widespread in Africa, having been reported from Algiers, Tripoli, Tunis, Egypt and the Sudan as well as from Madagascar. Cases have also been reported from Italy and Greece in Europe and from the West Indies and some of the South American countries. Several cases have been reported from North America and Sutton, in 1913, reported two cases from Kansas, one in a Mexican and one in a native of Texas.

ETIOLOGY AND EPIDEMIOLOGY

=Etiology.=—The disease is caused by the penetration of certain species of fungi into the tissues of the foot, although rarely the hand or some other part of the body may be affected. These species of fungus develop in granulomatous areas from which sinuses lead to the surface of the foot, in the discharges from which are found small granules resembling those found in the discharges from actinomycosis lesions.

As a rule only one kind of fungus is found in a single case. The most common infection is that due to _Discomyces madurae_ (_Nocardia madurae_) which is the fungus of the fish-roe-like granules of the pale or white variety of mycetoma. These, like the fungus of actinomycosis, _Discomyces bovis_, show a felted mycelium in the center and peripheral club-like structures. These granules are yellowish-white and vary in size from a pin’s head to a small pea. The mycelial threads are very narrow, 1 to 1½ microns. It grows aerobically and the cultures show slender mycelial threads which are Gram-positive. This is the organism of Carter’s white mycetoma.

Other species of the pale, white or ochroid group of mycetoma fungi are _Indiella mansoni_ (Brumpt’s white mycetoma), _Nocardia asteroides_ (Musgrave and Clegg’s white mycetoma), _Sterigmatocystis nidulans_ (Nicolle’s white mycetoma) and several others.

The cases caused by the black varieties are more rare and are characterized by the presence in the discharges from the sinuses of black gunpowder-like grains.

These hard, brittle, irregular grains are caused by various species of fungi of which the best known is Carter’s black mycetoma (_Madurella mycetomi_). This species was cultured by Wright and first shows a grayish growth, later becoming black. Other black varieties of mycetoma are due to various other fungi. Bouffard’s black variety is caused by _Aspergillus bouffardi_. DeBeurmann’s black mycetoma has as cause _Sporotrichum beurmanni_.

Besides the white and black varieties we also have a red variety of mycetoma. The fungus grains are quite small and reddish in color. It is not an uncommon infection in certain parts of Africa, as Senegal. The cause is _Nocardia pelletieri_.

Boyd and Crutchfield have noted an ascomycete in an American case, with white granules, to which has been given the name _Alleschiria boydii_.

=Epidemiology.=—We know very little about the occurrence of these mycetoma fungi, other than in man. It is thought that such fungi lead a saprophytic existence on thorns or blades of grass or spine-like grains of various cereals. Thus Nicolle’s case in Tunis started from a puncture wound by a grain of barley.

As the vast majority of such cases are noted in the feet, and as such cases are chiefly in those who work barefooted, it seems reasonable to consider that the fungi are introduced on some puncturing object and the external wound having healed development goes on in the deeper structures.

PATHOLOGY

In more than 75% of cases of mycetoma the foot is the only part infected. More rarely there is involvement of hands, knees and buttocks.

The affected part shows nodules on the external surface which connect with the granulomatous lesions of the interior of the foot by sinuses. In advanced cases there may be a network of sinuses and cyst-like dilatations which are filled with a viscid fluid packed with the small fish-roe granules in the white variety or the gunpowder grains of the black mycetoma. The bony structures of the foot may undergo disintegration as well as muscular and areolar tissue so that on cutting into such a foot there is nothing normal remaining—simply a cheesy mass.

In the early granulomatous areas are found the actinomyces-like granules surrounded by an area of mononuclear and polymorphonuclear infiltration. Giant cells are occasionally found. There is an inflammatory oedema. Externally we have connective tissue cells and a fibrous wall. The blood vessels show endothelial proliferation and thrombosis.

SYMPTOMATOLOGY

The disease usually begins in the sole of the foot with the formation of firm swellings about ½ inch in diameter. The cases are rarely seen at this stage, the natives waiting before seeking medical advice until the nodule has softened and begun to discharge the viscid fluid with the various-colored granules floating in it. As stated before, the soft, yellowish-white, fish-roe-like granules are most commonly observed, the more friable, hard, gunpowder-like grains less so. The nodules continue to form and to break down until the foot has become greatly enlarged, the under surface bulging out in a convex mass with the toes and heels appearing as if raised up. The dorsal surface is also puffed up and studded with broken down nodules, and the sides well rounded. There is no increase in the length of the foot. This swollen distorted foot is borne on a thin peg-like leg which makes the size of the foot more striking. Very rarely cases have been reported where the hand or thigh have been involved.

If one probes the discharging sinuses bone may or may not be felt according to the advancement of the degenerative changes. There is rarely pain or bleeding following the probing.

It is more from the onerous burden of carrying around this fungoid mass of a foot, 3 or 4 times the normal size, than pain, that the patient complains of.

[Illustration: FIG. 126.—Mycetoma. (From Greene.)]

Uncomplicated cases do not show fever and the occasional enlargement of lymphatic glands is probably connected with bacterial infections.

There are never visceral metastases in mycetoma as is true of the nearly related actinomycosis.

The process shows no tendency to heal naturally or under treatment but fortunately does not extend, the process being confined to a foot or a hand. The joints are rarely if ever invaded. Unless the sinus-riddled member is amputated the drain on the patient gradually exhausts him and death ensues in ten or fifteen years.

DIAGNOSIS

The distorted appearance of the foot or hand, riddled with sinuses discharging a viscid fluid containing the variously colored granules, which upon microscopical examination are found to be sclerotia of fungi, is absolutely diagnostic. As regards recognition of the causative fungus one should culture the discharge or grains on maltose agar, potato or rather dry blood serum. The recognition of species of fungi is a very difficult matter, even for an expert.

PROGNOSIS

This is absolutely unfavorable as regards the relief of the condition but as regards life it is not unfavorable provided the drain on the system is gotten rid of by amputation of the part.

PROPHYLAXIS AND TREATMENT

=Prophylaxis.=—The wearing of shoes in the fields or forests would seem to be the best means of protection against small wounds from thorns, splinters and the like.

Then, too, any such wound which might occur should be treated with tincture of iodine.

[Illustration: FIG. 127.—Important tropical fungi.]

=Treatment.=—It is usual to try the effects of curetting the lesions and if taken early enough this may have effect. As a rule the process goes on but is limited to the member attacked so that amputation of the diseased part brings about a cure. Iodide of potash is of no value. X-ray treatment seems to be of value in relieving the pain and in lessening the discharge from the sinuses but is of questionable curative effect. It might be of greater value if tried early in the disease.

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