It is described as
chronic swelling, induration and sinus formation with the discharge
of fungal grains, involving the skin, subcutaneous tissue and bone,
usually in the lower limb.
The syndrome is
caused by a variety of different fungi (eumycetes), and also by
aerobic actinomycete bacteria. Differentiation is important because
of the different patterns of response to treatment.
For Chaaria the
occurrence of Madura foot is sporadic, although not very rare, and
normally only in pastoralist patients coming from the North of the
Country.
The clinical
presentation is normally of painless swellings of the lower limbs
(more rarely of hands, back and head). The swelling is chronic and
after several years nodules form in the skin and break down to form
discharging sinuses from which pus and fungal grains emerge. Normally
there are no systemic symptoms unless infection occurs.
The progress is slow
but relentless. It may be a life-long condition.
The diagnosis is
normally clinical.
For confirmation
purposes we usually do a biopsy with collection of the grains, and we
send for cytology and histopathology. Normally we also check X-Rays
to rule out bone erosions and osteomyelitis.
Most of the cases we
have diagnosed in Chaaria are caused by the Eumycete Madurella
mycetomatis. The treatment has generally been disappointing,
although, following some international guidelines, we always try long
term medication: we use ketoconazole 200 mg twice daily for up to 12
months.
In the frequent case
of treatment failure we attempt surgical excision of the mycetoma,
taking care of being very wide and not rupturing the capsule that
often surrounds the infection. If there are few nodules sometimes we
are successful in this way, but in larger infections like the one
shown in today’s pictures, relapse is almost the rule. In bigger
and infected lesions, above all when the limb has been rendered
useless, we have done amputations, but sadly even after this
destructive procedure, relapse is likely.
There is evidence
that the organisms are spread from the environment via a penetrating
injury such as a thorn prick. The fungal causes of mycetoma have been
isolated from plants and plant debris, while actinomycetes have been
isolated from soil.
The condition is
more common in males but the photos we present refer to a young woman
of Borana tribe who is at the moment on medical treatment.
SOURCES
- G. V. GILL, N.J. BEECHING, LECTURE NOTES ON TROPICAL MEDICINE. BLACKWELL PUBLISHING. FIFTH EDITION
- MANSON’S TROPICAL DISEASES, TWENTY-FIRST EDITION. ELST WITH SAUNDERS
Br Dr Giuseppe Gaido
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