Subcutaneous Mycoses

Mycetoma & Rhinosporidiosis

Dr. N. M. Suryawanshi, MD Assistant Professor, MIMSR Medical College, Latur.

Introduction
Heterogeneous group of fungal infections characterized by development of clinical lesions in subcutaneous tissues at the site of inoculation of etiological agents. Disease process starts following trivial trauma

Subcutaneous Mycoses
Mycetoma Rhinosporidiosis Sporotrichosis

Chromoblastomycosis
Phaeohyphomycosis

Lobomycosis

Mycetoma
Slowly progressive, chronic granulomatous infection of skin & subcutaneous tissues with involvement of underlying fasciae & bones usually affecting extremities.

 Characterized by triad of
Tumefaction of affected tissue Multiple draining sinuses Oozing granules

Madura foot / Maduramycosis

Madura foot

Causative agents
Caused by two groups Eumycetoma
Eumycetes i.e. true fungi

Actinomycetoma
Actinomyctes i.e. aerobic filamentous
bacteria

Causative organisms
Fungal agents
Madurella mycetomatis Madurella grisea Exophiala jeanselmei Curvularia geniculata
Pseudallescheria boydii Aspergillus nidulans Acreonium falciforme Fusarium species
Black grain eumycetoma

White grain eumycetoma

Causative organisms
Bacterial agents
Actinomadura madurae Actinomadura pelletieri Nocardia brasiliensis Nocardia caviae Nocardia asteroides Nocardiopsis dassonvillei Streptomyces somaliensis

Epidemiology
Prevalent in almost all parts of the world More common in tropical & subtropical countries In India
Tamil Nadu Rajasthan

Epidemiology
More prevalent in developing countries

Incidence is more in rural areas

Common in 20 to 40 years

Common in men than women

Occupational groups farmers, carpenters,

land workers
Habit of working barefooted

Pathogenesis
Introduction of causative agents Mycetoma of extremities
Thorn-prick injury

Mycetoma of Ear
Use of wicks for removal of earwax

Mycetoma of back
Carrying wood, grain bags, stone on back

Mycetoma of head & neck

Carrying bundles of wood on head & neck

Pathogenesis & Pathology

After introduction disease evolves slowly Organisms are usually found in the center of microabscess formed by PMN cells Main characteristic is the presence of large aggregates of filaments of causative organisms

Clinical features
Characterized by triad of
Tumefaction i.e. Tumor-like swelling Formation of multiple draining sinuses Grains/granules oozing from sinuses

Painless localized swollen lesions

Sinuses discharge serous, sero-sanguineous

or purulent fluid

 Mainly affects feet but hands, shoulder, buttocks, scalp have also been reported Disease progresses slowly takes often years

Spreads by contiguity & continuity destroying

surrounding structures except tendons & nerves

Hematogenous spread seen in Nocardia &

Streptomyces species

Laboratory diagnosis
Detailed & proper history
Occupation Trauma Geographical area of patient

Sample
Usually grains or granules Pus

Exudates
Biopsy

Collection of sample
Lesions cleaned thoroughly with antiseptics Grains are collected by pressing sinus from periphery to enhance discharge

Discharge collected on sterile gauze

Alternatively, can be collected with loop

If more grains needed, flap of orifice of sinus are

opened & collected in sterile petri dish

Gross examination of grains

Size Shape

Texture
Colour

Cement-like matrix

Characteristics of grains
Fungal agents 1. Black grain Eumycetoma
Madurella mycetomatis Madurella grisea Exophiala jeanselmei Curvularia geniculata Hard Soft Soft Hard 0.5-5.0 0.3-0.6 0.2-0.3 0.5-1.0 Oval, lobed Oval, lobed Irregular Oval Present Present Absent Present

Texture

Size mm Shape

Cement-like matrix

2. White grain Eumycetoma

Pseudallescheria boydii Aspergillus nidulans Acremonium falciforme Fusarium species Soft Soft Soft Soft 0.5-1.0 1.0-2.0 0.2-0.5 0.2-0.6 Oval, lobed Oval Oval Oval Absent Absent Absent Absent

Characteristics of grains
Bacterial agents Actinomadura madurae Colour White, yellow Size mm 2.0

Actinomadura pelletieri Nocardia brasiliensis

Nocardia caviae Nocardia asteroides

Pink, red Yellowish-white

White-yellow White-yellow

0.5 < 0.5

< 0.5 < 0.5

Streptomyces somaliensis

Yellowish white

1.0

Microscopic examination
KOH examination Eumycotic grains
Thick, 2-6 m wide hyphae with large cells upto 15 m at margin with or without chlamydospores

Actinomycotic grains
Thin, 0.5- 1 m wide filaments with coccoid or bacillary forms

Stains
Gram stain
Gram-positive branching filamentous bacteria embedded in grain material

Modified ZN stain (Kinyouns method with 1% H2SO4)

Pink colored filamentous bacteria i.e. Nocardia spp.

Culture
When Actinomycetoma is suspected Grains are washed with normal saline without antibiotics
SDA without antibiotics Blood agar LJ media BHI agar

When Eumycetoma is suspected Grains are washed with normal saline with antibiotics
Emmons modified SDA (SDA with antibiotics like gentamicin, chloramphenicol )

Agents Bacterial Agents

- Actinomadura madurae
- Nocardia

Colony

Stain

Dry, wrinkled ,hard

GM Positive, non Fragmented filaments GM positive branched filaments, fragment to form acid fast bacilli GM positive branched filaments, non-fragmentary to form non-acid fast bacilli

Dry,yellow-orange,chlaky, Wrinkled, show yellow and

brasiliensis brown sectoring

- Streptomyces somaliensis

Agents Fungal Agents

Madurella
Mycetomatis

Colony
O- folded, leathery, white to yellow
R- Dark brown

LCB /stain

Septate hyphae with chalamydospores

pointed conidiophore, flask-shaped

phialides with ovoid conidia

M. grisea

O- folded, leathery, gray R- brown-black O- velvety black R- black O- Floccose brown black R- Black

Brown septate hyphae, arthrospores in chains Pigmented hyphae, tapering Conidiophores with aggregates of oval conidia Conidiophores bearing transversely septate, conidia, slightly curved with large central cell

- Exophiala jeanselmei Curvularia geniculata

Immunodiagnosis
Complement fixation test Immunodiffusion test Counterimmunoelectrophoresis

ELISA
Western blot

Treatment
Eumycetoma
Oral ketoconazole 200 mg BD & Itraconazole 100 mg BD for 8-24 months Amphotericin B

Actinomycetoma
Co-trimoxazole Tetracycline Streptomycin Amoxycillin-clavulanate Amikacin

Rhinosporidiosis
Chronic granulomatous disease of mucous membrane characterized by polyposis of nasal cavity, conjunctiva & other body sites

Causative agent
Rhinosporidium seeberi

Life cycle
3 principle stages Maturation of trophocyte Development of sporangia

Production of endospores

 Trophic stage in tissue

Rounded or oval structure, 6-8 m size with cytoplasm, cell

membrane, nucleus & nucleolus Mitotic division

Increase in size (140 m) & wall thickness

Develops into sporangium containing approximately 12,000 16,000 endospores

Sporangium has outer chitinous & inner cellulose membrane

with germinal spore eccentrically

Release of endospores
Release occurs by two ways When inside pressure is high
sporangium ruptures at weak point of wall

When it is not high

spores are released one by one through pore

After release enter in surrounding tissue and enter in

connective tissue or carried by lymphatics .

Epidemiology
Generally prevalent in India, Sri lanka, Argentina & Brazil In India
Tamil Nadu, Kerala, Pondicherry, Andhra Pradesh, West
Bengal & Chhattisgarh

Fresh & stagnant water act as reservoir of infection

Epidemiology
Age distribution:20-40 yrs Sex distribution :M >F Sites: Nose, Eyes, Skin, genitals Predisposing Factors: Common in people who take bath along with domestic animals in polluted water with acid PH which favours growth of fungus Risk occupations: Paddy cultivators, Sand workers

Clinical features
Nasal Rhinosporidiosis
Friable polypoid, vascular lesion, Bleed easily Papillary projections & lobules give raspberry, stawberry or cauliflower-like appearance Epistaxis, unilateral nasal obstruction, foreign body sensation

Occular Rhinosporidiosis

Cutaneous Rhinosporidiosis
Miscellaneous Rhinosporidiosis (genital rhinosporidiosis)

Rhinosporidiosis of nose & eye

Laboratory diagnosis
Specimen
Dischage / biopsy

Collection and Transport

Nasal washings collected by pushing saline and aspirating back

Microscopic exam
Histopathological examination is important Hyperplastic connective tissue Sporangium with thick hyaline wall of size 200-300 m in diameter filled with endospores

Culture
Not possible to grow on artificial culture media Can grow in vivo in an epithelial carcinoma cell culture lines

No serological tests available

Treatment
Radical surgery Dapsone-DDS for recurrent cases