Madura foot diagnosis and management

Madura foot diagnosis and management

Madura foot diagnosis and management

This is a descriptive term for a group of chronic infectionsof the subcutaneous tissues and bone of - usually, but notinvariably - the limbs. Two groups of organisms cause thiscondition: Actinomycetes cause 60% of cases; these are bacteriaand respond to antibiotics. True fungi such as Madurella mycetomatis, which arealmost totally unresponsive to antifungal drugs.These two groups of organisms are found in the soil andenter the skin by penetrating injuries.

Pathology and clinical features The main features are chronic inflammation with microabscessesand granulomatous reactions around collections ofthe organisms. The organisms spread slowly along fascialplanes and not via lymphatic or haematogenous routes.Collections of organisms forming adjacent to bone producelocal resorption, and small lytic areas visible on X-ray.There are also areas of reactive sclerosis. Sinuses form andorganisms are extruded. There is swelling of the affectedarea, with often prominent subcutaneous nodules. The timecourse is slow, and although there may be recollection of apenetrating injury, such as a thorn going deeply into the footin childhood, there is often no such history and presentationmay occur years after the patient has left an endemic area.

Investigations and management The most important investigation is an adequate surgicalbiopsy of diseased tissue, which must usually go down tobone. This specimen is divided to give samples forhistology and culture for the two groups of organisms.Actinomycetoma responds well to prolonged courses ofantibiotics. Co-trimoxazole is effective (two tablets twicedaily for 9 months, with streptomycin 1 g intramuscularlydaily for the first 2 months). Dapsone, 100mg daily, is analternative to co-trimoxazole. Pigmented grains fungi mayrespond to ketoconazole, whereas non-pigmented speciesare treated with itraconazole. Madurella mycetomatishas responded to ketoconazole 200 mg twice daily, andAspergillus nidulans, A. flavus and Fusarium species haveresponded to 100 mg twice daily, in prolonged courses. Surgicalremoval of diseased tissue in addition to antifungalagents is recommended for some fungal infections.

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