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Mycetoma

Mycetoma is an important parasitic disease in arid and semi-arid regions around the globe. It is found in Brazil, Mexico, the Sahel, in pan-Arabia, and in semi-arid areas of India. It is found as far north as Romania. more...

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There are two forms of mycetoma. At the level of electron microscopy the two forms of mycetoma are difficult to distinguish from one another. The two forms of mycetoma are bacterial mycetoma and fungal mycetoma. Bacterial mycetoma is known as actinomycetoma. Fungal mycetoma is known as eumycetoma.

The disease is usually acquired while performing agricultural work. It generally afflicts men between 20 and 40 years old. Most infections appear initially in the foot or hand. The disease is characterized by a yogurt-like discharge upon maturation of the infection. The disease travels via the lymphatic system. Infections normally start in the foot or hand and travel up the leg or up the arm.

The disease is acquired by contacting grains of bacterial or fungal spores that have been discharged onto the soil. Infection usually involves an open area or break in the skin.

Diagnosis of mycetoma is usually accomplished by radiology, ultrasound or by fine needle aspiration of the fluid within an afflicted area of the body.

There are several clinical treatments available for this disease. They include surgery, Ketoconazole, Itraconazole and amputation.

There is no sure-fire treatment available at this date. Nor is there available at this date a vaccine for mycetoma.

Scientists at such institutions as The Mycetoma Research Center at The University of Khartoum in the Sudan are working on a cure.

Causative species

Species of bacteria that cause Mycetoma include:

  • Actinomadura madurae
  • Actinomadura pelletierii
  • Streptomyces somaliensis

Species of fungus that cause Mycetoma include:

  • Madurella myceomatis.

Read more at Wikipedia.org


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Pseudoallescheria boydii breast implant infection in a lung transplant recipient
From CHEST, 10/1/05 by Hina Sahi

INTRODUCTION: Pseudoallescheria boydii is a ubiquitous fungus present in soil, sewage and polluted waters. Although the clinical spectrum is wide, the most frequent disease in immunocompetent individuals is a mycetoma. An increasing number of cases of disseminated infections are reported in immunocompromised patients yet a review of the lung transplant literature yields relatively few cases of disseminated infection. The clinical and histopathological presentation of Psedoallescheria boydii infection is similar to Aspergillus spp and Fusarium spp; therefore culture is necessary to make the correct diagnosis. This is especially relevant since infection due to Psedoallescheria boydii is often resistant to antimycotic drugs such as Amphoterecin B and Flucytosine, which are commonly used to treat Aspergillus infections.

CASE PRESENTATION: A 57-year-old female patient, status post a right single lung transplant 14 months ago for COPD, presented to the hospital with complaints of severe left mastalgia. She had bilateral silicone breast implants placed twenty five years ago. She was maintained on routine triple drug therapy consisting of Tacrolimus, Mycophenolate mofetil and Prednisone. She was also on routine opportunistic infection prophylaxis with Itraconazole, Valgancyclovir and Trimethoprim-Sulfamethaoxazole. Recently the patient was diagnosed with Grade A1B0 acute rejection on surveillance bronchoscopy which had not resolved inspite of two treatments with pulse steroids. The patient reported a one week history of severe, continuous left breast pain with concomitant tight sided pleuritic chest pain. In addition she had developed painful skin lesions on both thighs and blurting of vision. On examination the left breast was swollen, warm and exquisitely tender to touch around the implant capsule.

She had multiple skin lesions which were approximately one centimeter in diameter, red, warm, tender and nonblanching. Neurological exam revealed ptosis of the left eyelid and third cranial nerve palsy. CT scan chest showed a loculated right pleural effusion suggestive of empyema and a persistent right lower lobe parenchymal nodule. Skin biopsy from the thigh lesion revealed a fungal abscess with pseudohyphae consistent with Pseudoallescheria spp. An MRI breast revealed marked inflammatory enhancement around the left silicone breast implant. Bilateral breast implants were emergently surgically removed. Microscopic evaluation of the left implant capsule demonstrated evidence of invasion by fungal hyphae. MRI brain revealed multiple ring enhancing lesions in the parenchyma suggestive of a hematogenously disseminated infection. The patient was treated with high dose intravenous Voriconazole. Multiple tissue cultures grew Pseudoallescheria boydii. We suspect that the initial nidus was the pulmonary nodule, with hematogenous dissemination at a time of increased immunosuppression. We were unable to identify a definite exposure inspite of extensive questioning. This makes it difficult to predict any future re-infection.

DISCUSSIONS: P.boydii may cause life-threatening illness in the lung transplant population. Early diagnosis should be done by fungal culture so that adequate therapy may be initiated. In the pre Voriconazlole era, disseminated infection in the lung transplant population was uniformly fatal. However in recent years there have been some treatment successes with the use of Voriconazole. To our knowledge this is the first reported case of breast implant infection with Psedoallescheria boydii in the lung transplant population. This raises questions regarding the safety of these foreign bodies in an immunosuppressed population prone to opportunistic infections. There may be a case here for removal of such foreign bodies prior to transplant. We reviewed our lung transplant database but could not identify any other case of breast implant infection.

CONCLUSION: Cosmetic foreign bodies in a lung transplant recipient have the potential to be infected, due to the immune suppressed nature of the patient. There should be a low threshold to remove such implants during the pre-transplant work up, if agreeable to the patient.

DISCLOSURE: Hina Sahi, None.

Hina Sahi MD * Marie Budev DO Robin Avery MD Cleveland Clinic Foundation, Cleveland, OH

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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