Mycopathologia vol. 57, 1, pag. 27-29, 1975
BLACK G R A I N M Y C E T O M A - 2 CASE R E P O R T S
A. K A M A L A M , Patrick YESUDIAN & A. S. THAMBIAH Department of Dermatology, Madras Medical College & Government General Hospital, Madras, India
Abstract
Two cases of black grain mycetoma, one owing to Madurella grisea and the other due to M. mycetomii have been reported. The clinical features appear to be less florid than that occurring in actinomycotic mycetoma. There was no bone involvement in either of the two cases. These two are the first cases of black grain mycetoma from our institution.
Introduction
Mycetoma caused by the true fungi have been met with only occasionally when compared to those caused by the actinomycetales, in the State of Tamil Nadu. Out of 20 cases of mycetoma recorded during the past 5 years in the Department of Dermatology, Government General Hospital, Madras, only 2 were found to be due to true fungal infection, the others being Streptomyces and Nocardia species. We report here 2 cases of black grain mycetoma, one caused by Madurella grisea and the other by M. mycetomii.
Case report:
Case 1 : A 40 year old male farmer was admitted to the Skin ward on 18-4-1972 for complaints of swelling over the left foot and anke of one year duration. Injury of the same foot by a stone prior to the onset of illness was obtained. The abscess which developed following this injury healed spontaneously in few days but in few weeks time new nodules appeared on the ankle excuding pus and black grains. Over the course of a year there were fresh nodules; bursting and healing of these occurred periodically and involved the whole foot and ankle (fig. 1). There was little pain since 6 months. The nodules varied from
Fig. 1. Mycetoma left foot and ankle caused by M. grisea(case 1). 2 to 5 mm size and were particularly numerous over the medial side of the foot. The healed ones had left behirltt puckered scars. Skin over the entire foot was hyperpigmented and thickened. He had scabies infection in addition. Systemic examination did not reveal any abnormality. Total serum proteins were 6.7 Gin. with albumin of 3.3 Gm and Globulin of 3.4 Gm. The other laboratory investigations done routinely were noncontributory. The grains on manual expression were black, of 1 to 3 mm size with an irregular shape and no particular odour. In KOH mount showed septate hyphae and chlamydospores. The configuration was typical with an uniform border on one side and serrated margin containing the chlamydospores on the other and resembled a half moon (fig. 2). All grains were dark brownish black and hard. Biopsy of the nodule showed an acanthotic epidermis and the dermis filled with cells consisting of lymphocytes, plasma cells, eosinophils and pigment laden macrophages. The grain of Madurella spp. was visualised (fig. 3) in the deep dermis similar to the appearance in the wet mount. X-ray of the affected foot showed sclerosis of the calcaneum but no osteolytic or periosteal reaction. Soft tissue shadow was 27
not predominant as with the group of actinomycotic infection that is seen in our cases. On Sabouraud's dextrose agar the grains produced grey to greyish green colonies with black pigment on the reverse in 4 days, attaining a size of 1 cm in 2 weeks. Microscopically septate hyphae and chlamydospores were seen but no conidia. The strain was identified as M. grisea by utilisation of maltose, glucose and sucrose but not lactose. The patient was given Dapsone 200 mg daily along with chloramphenicol for 4 weeks but showed no improvement and was discharged from the hospital at request.
Fig. 2. Black grains of M. 9r~ea in KOH mount ( x 00).
Fig. 3. Grain of M. grisea in the dermis (PAS stain, x 120).
Case 2: A 50 year old male farmer was admitted in the Skin ward in November 1972 with swelling and nodules of left foot of 1 year duration. His foot showed (fig. 4) a single nodule and the skin of the same foot was hyperpigmented. He also had a firm nodule of 2 cm over left side forehead. The nodule of the foot on manual expression exuded black grains which were inoculated on to Sabouraud's dextrose agar. After a week a buff coloured colony developed, attaining a c m in another week. Over this period the buff colour became more intense and a melonotic pigment appeared and found to diffuse into the medium and on the reverse of the colony. On the 3rd week there were moist globular deposits at the centre of the colonies. Microscopically septate hyphae and a few phialides were visualised. The strain utilised lactose, glucose and maltose but not sucrose. On these findings the species was identified as M. mycetornii. A biopsy study was not possible as there was no other lesion. Systemic examination did not reveal any abnormality. The forehead lesion revealed an abscess but no grains visualised. Griseofulvin 1 Gm in divided doses was given for a period of 2 months with no appearance of fresh nodules. The swelling and pigmentation of the foot persisted. He was sent home with an advice to return after a month for review and to continue griseofulvin. The patient has not reported for review to date.
Comment
Fig. 4. Mycetoma left foot caused by M. mycetomii (case 2). 28
Cases of mycetoma have been encountered more frequently than any other deep mycoses in our clinic. Among the 20 cases studied in the past 5 years only 2 cases were lbund to be due to true fungal agents (10~o), both being Madurella group. Compared to the florid lesions observed (1) in actinomycotic mycetoma the patients reported here showed fewer nodules. There was no significant bone in-
volvement in both the cases in contrast to the extensive bone destruction in the actinomycotic group especially in Streptomyces infection (2). No systemic involvement has been observed in the 2nd case as has been reported (5). Isolation of these two fungi in the above cases suggests the existence of these species in South India (3) as they exist in North India (4). Absence of new nodule in the 2nd case may mean either that the organism was sensitive to the drug or that the duration of observation was too short for any comment. The value of Dapsone in our 1st case is difficult to assess as the period was too short, though its value has been discussed (5) in black grain mycetoma.
Summary Two cases of mycetoma due to true fungal agents are reported with their clinical and mycological findings. M. grisea in one and M. mycetomii in the other were the agents. Dapsone in M. grisea and griseofulvin in M. mycetomii were given. Though the patients improved with treatment, the value of the drugs could not be assessed as the duration of therapy was too short.
Acknowledgement We thank Prof. L. N. Mohapatra, All India Institute of Medical S c i - nces, New Delhi for confirming the species in the second case.
References 1. Kamalam, A. et al. 1972. Nocardiosis-2 case reports. Aust. J. Derm. 13: 69-74. 2. Kamalam, A. et al. Restoration of Bones in Mycetoma. Under publication. 3. Koshi, G. et al. 1972. Causal agents in Mycetoma of the foot in Soiithern India. Sabouraudia 10: 14-18. 4. Thammayya, A. et al. 1974. The causal agents of Black grain Mycetoma in Bengal. Ind. J. Derm. & Vener. 40: 11~116. 5. Vanbreuseghem, R. 1967. Early diagnosis, treatment and epidemiology of Mycetoma. Rev. med. vet. Mycol. 6: 49-60.
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BLACK G R A I N M Y C E T O M A - 2 CASE R E P O R T S
A. K A M A L A M , Patrick YESUDIAN & A. S. THAMBIAH Department of Dermatology, Madras Medical College & Government General Hospital, Madras, India
Abstract
Two cases of black grain mycetoma, one owing to Madurella grisea and the other due to M. mycetomii have been reported. The clinical features appear to be less florid than that occurring in actinomycotic mycetoma. There was no bone involvement in either of the two cases. These two are the first cases of black grain mycetoma from our institution.
Introduction
Mycetoma caused by the true fungi have been met with only occasionally when compared to those caused by the actinomycetales, in the State of Tamil Nadu. Out of 20 cases of mycetoma recorded during the past 5 years in the Department of Dermatology, Government General Hospital, Madras, only 2 were found to be due to true fungal infection, the others being Streptomyces and Nocardia species. We report here 2 cases of black grain mycetoma, one caused by Madurella grisea and the other by M. mycetomii.
Case report:
Case 1 : A 40 year old male farmer was admitted to the Skin ward on 18-4-1972 for complaints of swelling over the left foot and anke of one year duration. Injury of the same foot by a stone prior to the onset of illness was obtained. The abscess which developed following this injury healed spontaneously in few days but in few weeks time new nodules appeared on the ankle excuding pus and black grains. Over the course of a year there were fresh nodules; bursting and healing of these occurred periodically and involved the whole foot and ankle (fig. 1). There was little pain since 6 months. The nodules varied from
Fig. 1. Mycetoma left foot and ankle caused by M. grisea(case 1). 2 to 5 mm size and were particularly numerous over the medial side of the foot. The healed ones had left behirltt puckered scars. Skin over the entire foot was hyperpigmented and thickened. He had scabies infection in addition. Systemic examination did not reveal any abnormality. Total serum proteins were 6.7 Gin. with albumin of 3.3 Gm and Globulin of 3.4 Gm. The other laboratory investigations done routinely were noncontributory. The grains on manual expression were black, of 1 to 3 mm size with an irregular shape and no particular odour. In KOH mount showed septate hyphae and chlamydospores. The configuration was typical with an uniform border on one side and serrated margin containing the chlamydospores on the other and resembled a half moon (fig. 2). All grains were dark brownish black and hard. Biopsy of the nodule showed an acanthotic epidermis and the dermis filled with cells consisting of lymphocytes, plasma cells, eosinophils and pigment laden macrophages. The grain of Madurella spp. was visualised (fig. 3) in the deep dermis similar to the appearance in the wet mount. X-ray of the affected foot showed sclerosis of the calcaneum but no osteolytic or periosteal reaction. Soft tissue shadow was 27
not predominant as with the group of actinomycotic infection that is seen in our cases. On Sabouraud's dextrose agar the grains produced grey to greyish green colonies with black pigment on the reverse in 4 days, attaining a size of 1 cm in 2 weeks. Microscopically septate hyphae and chlamydospores were seen but no conidia. The strain was identified as M. grisea by utilisation of maltose, glucose and sucrose but not lactose. The patient was given Dapsone 200 mg daily along with chloramphenicol for 4 weeks but showed no improvement and was discharged from the hospital at request.
Fig. 2. Black grains of M. 9r~ea in KOH mount ( x 00).
Fig. 3. Grain of M. grisea in the dermis (PAS stain, x 120).
Case 2: A 50 year old male farmer was admitted in the Skin ward in November 1972 with swelling and nodules of left foot of 1 year duration. His foot showed (fig. 4) a single nodule and the skin of the same foot was hyperpigmented. He also had a firm nodule of 2 cm over left side forehead. The nodule of the foot on manual expression exuded black grains which were inoculated on to Sabouraud's dextrose agar. After a week a buff coloured colony developed, attaining a c m in another week. Over this period the buff colour became more intense and a melonotic pigment appeared and found to diffuse into the medium and on the reverse of the colony. On the 3rd week there were moist globular deposits at the centre of the colonies. Microscopically septate hyphae and a few phialides were visualised. The strain utilised lactose, glucose and maltose but not sucrose. On these findings the species was identified as M. mycetornii. A biopsy study was not possible as there was no other lesion. Systemic examination did not reveal any abnormality. The forehead lesion revealed an abscess but no grains visualised. Griseofulvin 1 Gm in divided doses was given for a period of 2 months with no appearance of fresh nodules. The swelling and pigmentation of the foot persisted. He was sent home with an advice to return after a month for review and to continue griseofulvin. The patient has not reported for review to date.
Comment
Fig. 4. Mycetoma left foot caused by M. mycetomii (case 2). 28
Cases of mycetoma have been encountered more frequently than any other deep mycoses in our clinic. Among the 20 cases studied in the past 5 years only 2 cases were lbund to be due to true fungal agents (10~o), both being Madurella group. Compared to the florid lesions observed (1) in actinomycotic mycetoma the patients reported here showed fewer nodules. There was no significant bone in-
volvement in both the cases in contrast to the extensive bone destruction in the actinomycotic group especially in Streptomyces infection (2). No systemic involvement has been observed in the 2nd case as has been reported (5). Isolation of these two fungi in the above cases suggests the existence of these species in South India (3) as they exist in North India (4). Absence of new nodule in the 2nd case may mean either that the organism was sensitive to the drug or that the duration of observation was too short for any comment. The value of Dapsone in our 1st case is difficult to assess as the period was too short, though its value has been discussed (5) in black grain mycetoma.
Summary Two cases of mycetoma due to true fungal agents are reported with their clinical and mycological findings. M. grisea in one and M. mycetomii in the other were the agents. Dapsone in M. grisea and griseofulvin in M. mycetomii were given. Though the patients improved with treatment, the value of the drugs could not be assessed as the duration of therapy was too short.
Acknowledgement We thank Prof. L. N. Mohapatra, All India Institute of Medical S c i - nces, New Delhi for confirming the species in the second case.
References 1. Kamalam, A. et al. 1972. Nocardiosis-2 case reports. Aust. J. Derm. 13: 69-74. 2. Kamalam, A. et al. Restoration of Bones in Mycetoma. Under publication. 3. Koshi, G. et al. 1972. Causal agents in Mycetoma of the foot in Soiithern India. Sabouraudia 10: 14-18. 4. Thammayya, A. et al. 1974. The causal agents of Black grain Mycetoma in Bengal. Ind. J. Derm. & Vener. 40: 11~116. 5. Vanbreuseghem, R. 1967. Early diagnosis, treatment and epidemiology of Mycetoma. Rev. med. vet. Mycol. 6: 49-60.
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