P242 Autochthonous cases of Madura foot from Jodhpur, Western Rajasthan, India
Authors: Nag Venkat Goutham , Azim Zeeshan Noore , Roy Nithya S. , Vishwakarma Kirti , Sharma Kirthika , Bhardwaj Abhishek , Jain Vidhi 
Published: September 2022

Abstract

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM
Mycetoma has been classified as a neglected tropical disease by the WHO. ‘Madura foot’ is a prominent presentation of phaeoid fungi Madurella complex in India. Maduromycotic mycetoma is frequently encountered in Western Rajasthan, where it is endemic. A high prevalence in this area is due to the desert climate of prolonged hot sunshine and scanty annual rainfall. The classic clinical ‘triad of Mycetoma’ involves a painless hard swelling, multiple fistulas, and discharge of grains.
We report two cases of eumycetoma from Western Rajasthan:
Case Report 1: A 41-year-old male, farmer presented a history of progressive swelling of the left foot in the last 4 years following trauma to the left sole 5 years ago. Patient took multiple treatments with no improvement. General examination showed a pallor and inguinal lymphadenopathy. Local examination revealed tumefaction with multiple sinuses discharging serosanguinous fluid with occasional black granules. Laboratory tests revealed hemoglobin of 6.2 g/dL. Serology was positive for Hepatitis B virus. Direct 40% KOH microscopy of the crushed grains shows septate branching phaeoid hyphae. Whitish brown dry colonies with diffusible brown pigment were seen on Sabouraud Dextrose Agar at 25°C. Lactophenol Cotton Blue Stain showed dark septate hyphae with chlamydoconidia. Histopathological studies confirmed Eumycetoma. X-rays of his foot showed large destructive bony lesions. Initial therapy given to patient was to correct anemia followed by specific antifungal treatment. A below knee amputation of left leg was performed once the anemia was corrected.
Case Report 2: A 55-year-old borderline diabetic male daily-wage worker presented with multiple nodular discharging lesions over the anterior shin of the right leg for past 7 years. The lesion started in leg as a small nodule that ruptured discharging black grains intermittently. He could not recall any significant trauma to his foot. Patient took multiple treatments with temporary relief but the disease recurred. Direct microscopy of 40% potassium hydroxide mount of the crushed grains showing thin septate branching phaeoid hyphae and on Sabourad Dextrose Agar at 25°C. White to brown color colony growth with diffusible brown pigment was seen after 2 weeks of incubation. X-rays indicated no bony involvement. Ultrasonographic study of lesions was suggestive of mycetoma. Patient was treated with itraconazole 400 mg/day for 4 days in the hospital and discharged subsequently.

Discussion
The foot is commonly involved in those with outdoor occupations. The combination of the clinical specific lesions, typical grains, microscopy, and histopathological studies are characteristic of the diagnosis. Radiodiagnosis is useful to determine the extension of the lesions in bone and other tissues. Combined medical and surgical treatment is recommended. Amputation is indicated in advanced mycetoma not responding to medical treatment with a severe secondary bacterial infection.

Conclusion
We hope to spread awareness regarding fungal eumycetoma due to Madurella spp, an endemic but neglected tropical disease in Western Rajasthan. Clinical suspicion coupled to direct KOH microscopy, fungal culture, and histopathology can yield a definitive diagnosis. Commencement of medical and/or surgical treatment at an early stage is necessary to prevent complications.