A client came in for a consultation, and basically as most health professionals would agree, you never know what you are going to see, or have to deal with. Many persons are laid back and leave things until it is really out of hand, becomes painful or is quite a discomfort. With foot related issues, it seems to be worse, as most would indicate… well it is my foot, so I never bothered with it.
With this particular condition, we were stumped. It was not something we had seen before. We were further torn on whether the person should have been referred to a surgeon or dermatologist. This is where a multidisciplinary approach is essential; within podiatry, you do focus a bit on dermatological conditions, however, it is not your specialisation, hence your knowledge base or scope is limited.
What is it?
That’s the burning question! It was referred to as Madura Foot back in the 1880s and is a fungus.It is a chronic infection of the skin and underlying tissues caused by both bacteria and fungi. Mycetoma (named because of the tumour-like mass it forms), has an inflammatory response and can extend to the underlying bone. Infection enters through sites of local trauma like a cut or splinter, causing a granulomatous reaction. The spread occurs through skin facial planes, and can involve the bone. It most commonly involves the foot but can involve the hands, back or shoulders.
-Mycetoma typically presents in agricultural workers (hands, shoulders and back – from carrying contaminated vegetation and other burdens), or in individuals who walk barefoot in dry, dusty conditions.
-Minor trauma allows pathogens from the soil or other surroundings to enter the skin.
-Following the initial injury, the disease typically follows a slow chronic course over many years, with painless swelling, and intermittent discharge of pus.
-There may be a deep itching sensation.
-Pain may occur due to secondary bacterial infection or bone invasion.
-After some years, massive swelling of the area occurs, with skin rupture and sinus tract formation. As the infection spreads, old sinuses close and new ones open.
-The exudates or discharges are typically granular.
-Microscopy and culture of exudates and skin biopsy for pathology are necessary to identify what is the causative organism.
-Serology can be helpful with diagnosis, or follow-up care during medical treatment.
-Plain X-rays are used to assess for evidence of bone involvement.
-CT scan may be more sensitive in the early stages.
-MRI scans can provide a better assessment of the degree of bone and soft tissue involvement, and may be useful in evaluating the differential diagnosis of the swelling.
Varied bacterial or fungus infections associated with the disease respond better to medical treatment than others, some are difficult to treat. Bone involvement complicates clinical management, often leaving surgical amputation as the only treatment option.
-Due to the slow, relatively pain-free progression of the disease, mycetoma is often at an advanced stage when diagnosed.
-Surgical debridement, followed by prolonged appropriate antibiotic therapy for several months may be required, combination therapy may be used, particularly in resistant cases.
-It can be partially responsive to antifungal therapy but can be treated by surgery, due to its normally well circumscribed nature.
-The disease causes disfigurement but is rarely fatal.
-In advanced cases, deformities or ankylosis may occur.
-Chronic neglected infection may necessitate amputation.
-Patients whose immune systems are compromised may develop invasive infection.
-Lymphatic obstruction and fibrosis may cause lymphoedema.
-Complications may result from toxicity due to prolonged antimicrobial or antifungal therapy.
-It can be cured with the appropriate antibiotic therapy but can sometimes has a high rate of recurrence and can require amputation.
-A high incidence of secondary bacterial infection in mycetoma lesions has been reported. This can cause increased pain and disability as well as septicaemia, which may be fatal if untreated.
Your feet mirror your general health . . . cherish them!