History

Fact Explanation
Asymptomatic Though actinomycetoma is a chronic disease it can be asymptomatic in some. [7]
Pain or discomfort at the site of inoculation Actinomycetoma is a rapidly progressing disease and patients may experience pain or discomfort initially which may be neglected. This is due to subcutaneous inflammation or due to secondary bacterial infection. [5,7,8]
Skin manifestations Patients usually present with painless subcutaneous swelling which develops into a subcutaneous nodule after few years. These nodules then indurate and forms a discharging sinus. [2,4,5]
Bone invasion Actinomycetoma can infect the bone and cause osteomyelitis. Patients complain of pain over the affected bone and may lead to functional disability. [6,7]
Deep itching sensation [8] This may be due to inflammation in the subcutaneous tissue and bone involvement.
History road traffic accidents or trauma Traumatic inoculation of the organism is a rare but possible way of acquiring the disease. [1,3]
References
  1. SAHA RAJDEEP, RIT KALIDAS. Actinomycetoma-recurrence after amputation. Ann Trop Med Public Health [online] 2013 December [viewed 11 May 2014] Available from: doi:10.4103/1755-6783.120988
  2. PALIT A, RAGUNATHA S, INAMADAR AC. Actinomycetoma: dramatic response to modified two-step regimen. Int J Dermatol [online] 2011 Apr, 50(4):446-9 [viewed 11 May 2014] Available from: doi:10.1111/j.1365-4632.2010.04681.x
  3. WELSH O, MORALES-TOQUERO A, VERA-CABRERA L, VAZQUEZ-MARTINEZ O, GóMEZ-FLORES M, OCAMPO-CANDIANI J. Actinomycetoma of the scalp after a car accident. Int J Dermatol [online] 2011 Jul, 50(7):854-7 [viewed 11 May 2014] Available from: doi:10.1111/j.1365-4632.2011.04874.x
  4. ARENAS ROBERTO, AMEEN MAHREEN. Giant grains of nocardia actinomycetoma. The Lancet Infectious Diseases [online] 2010 January [viewed 11 May 2014] Available from: doi:10.1016/S1473-3099(09)70347-0
  5. RATTANAVONG SAYAPHET, VONGTHONGCHIT SIVAY, BOUNPHAMALA KHAMHOU, VONGPHAKDY PHOUVONG, GUBLER JACQUES, MAYXAY MAYFONG, PHETSOUVANH RATTANAPHONE, ELLIOTT IVO, LOGAN JULIE, HILL ROBERT, NEWTON PAUL N, DANCE DAVID. Actinomycetoma in SE Asia: the first case from Laos and a review of the literature. Array [online] 2012 December [viewed 11 May 2014] Available from: doi:10.1186/1471-2334-12-349
  6. BONIFAZ A, GONZáLEZ-SILVA A, ALBRANDT-SALMERóN A, PADILLA MDEL C, SAúL A, PONCE RM. Utility of helical computed tomography to evaluate the invasion of actinomycetoma; a report of 21 cases. Br J Dermatol [online] 2008 Apr, 158(4):698-704 [viewed 11 May 2014] Available from: doi:10.1111/j.1365-2133.2008.08435.x
  7. JEREMY FARRAR, PETER HOTEZ, THOMAS JUNGHANSS, GAGANDEEP KANG, DAVID LALLOO, NICHOLAS J. WHITE. Manson's Tropical Diseases. Elsevier Health Sciences, Oct 26, 2013, pp. 1001.
  8. SAMAR KUMAR BISWAS. Postgraduate Companion in Orthopedics. JP Medical Ltd, Feb 1, 2013, pp. 122.

Examination

Fact Explanation
Examination of the involved skin Subcutaneous swelling, nodules, induration and discharging sinuses can be seen depending on the time of presentation. [1,2]
Regional lymphadenopathy [3] Lymphatic spread of organism to regional lymph nodes and secondary bacterial infection can cause regional lymphadenopathy.
Lymphedema Due to lymphatic obstruction and fibrosis. [4]
Signs of osteomyelitis Patients are febrile and have localized tenderness and swelling over the affected area. The range of movement is limited in the adjacent joints. Discharging sinuses is also an associated finding. [5]
References
  1. RATTANAVONG SAYAPHET, VONGTHONGCHIT SIVAY, BOUNPHAMALA KHAMHOU, VONGPHAKDY PHOUVONG, GUBLER JACQUES, MAYXAY MAYFONG, PHETSOUVANH RATTANAPHONE, ELLIOTT IVO, LOGAN JULIE, HILL ROBERT, NEWTON PAUL N, DANCE DAVID. Actinomycetoma in SE Asia: the first case from Laos and a review of the literature. Array [online] 2012 December [viewed 11 May 2014] Available from: doi:10.1186/1471-2334-12-349
  2. ARENAS ROBERTO, AMEEN MAHREEN. Giant grains of nocardia actinomycetoma. The Lancet Infectious Diseases [online] 2010 January [viewed 11 May 2014] Available from: doi:10.1016/S1473-3099(09)70347-0
  3. AUSTIN LIU, JENNIFER L MAENDER , NEIL COLEMAN, SYLVIA HSU, TED ROSEN. Actinomycetoma with negative culture: a therapeutic challenge. Dermatology Online Journal. [online] 2008: 14(4). [viewed 11 May 2014] Available from: http://escholarship.org/uc/item/19m6r34k
  4. SAMAR KUMAR BISWAS. Postgraduate Companion in Orthopedics. JP Medical Ltd, Feb 1, 2013, pp. 122
  5. PETER J. CAREK, LORI M. DICKERSON, PHARM.D., JONATHAN L. SACK. Diagnosis and Management of Osteomyelitis. Am Fam Physician. [online] 2001 Jun 15;63(12):2413-2421. [viewed 11 May 2014] Available from: http://www.aafp.org/afp/2001/0615/p2413.html

Differential Diagnoses

Fact Explanation
Aspergillosis Skin involvement in Aspergillosis presents as fever and macules, papules, nodules, or plaques. swelling, induration, and tenderness at the site of infection is also observed. Commonly seen in immune compromised patients. [5]
Eumycetoma Eumycetoma is caused by saprophytic micro-organisms found in the soil and on plant matter. This can be easily differentiated from actinomycetoma by microscopic examination of the tissue samples. (Biopsy or fine needle aspiration cytology) [1]
Perianal fistula Involvement of the perianal skin can cause perianal sinus tract formation. [2] Causes for perianal fistula like chronic constipation, diverticulitis and Chronn’s disease are known causes of perianal fistula formation.
Soft tissue tumours [3] These include lipoma, fibroma and sarcoma. All of these present with soft tissue swelling. Biopsy of the lesions will help in making the definitive diagnosis.
Chronic osteomyelitis [3] Chronic osteomyelitis can cause subcutaneous swelling and discharging sinuses.
Histoplasmosis [4] Skin erythema and ulceration are the usual clinical features. [6]
Chromoblastomycosis [4] This is also a fungal infection caused by fungus in phaohyphomycosis group, which produces sclerotic bodies, nodules, plaques and ulcers. [7]
Cutaneous tuberculosis [4] Actinomycetoma can mimic tuberculoid granulomas and scrofuloderma.
References
  1. AFROZ NISHAT, KHAN NAZOORA, SIDDIQUI FARHANA, RIZVI MEHAR. Eumycetoma versus actinomycetoma: Diagnosis on cytology. J Cytol [online] 2010 December [viewed 11 May 2014] Available from: doi:10.4103/0970-9371.73297
  2. CHáVEZ G, ESTRADA R, BONIFAZ A. Perianal actinomycetoma experience of 20 cases. Int J Dermatol [online] 2002 Aug, 41(8):491-3 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12207764
  3. RATTANAVONG SAYAPHET, VONGTHONGCHIT SIVAY, BOUNPHAMALA KHAMHOU, VONGPHAKDY PHOUVONG, GUBLER JACQUES, MAYXAY MAYFONG, PHETSOUVANH RATTANAPHONE, ELLIOTT IVO, LOGAN JULIE, HILL ROBERT, NEWTON PAUL N, DANCE DAVID. Actinomycetoma in SE Asia: the first case from Laos and a review of the literature. Array [online] 2012 December [viewed 11 May 2014] Available from: doi:10.1186/1471-2334-12-349
  4. JEREMY FARRAR, PETER HOTEZ, THOMAS JUNGHANSS, GAGANDEEP KANG, DAVID LALLOO, NICHOLAS J. WHITE. Manson's Tropical Diseases. Elsevier Health Sciences, Oct 26, 2013.
  5. VAN BURIK JA, COLVEN R, SPACH DH. Cutaneous Aspergillosis J Clin Microbiol [online] 1998 Nov, 36(11):3115-3121 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC105285
  6. MAMATHA GEORGE, SANDHYA GEORGE, UMA RAJAN, MUHAMMED KUNNUMMAL, ANZA KHADER. Syphilis of fungal world: Novel skin manifestations of histoplasmosis in an immunocompetent host. Indian J Dermatol [online] 2012 December [viewed 11 May 2014] Available from: doi:10.4103/0019-5154.103089
  7. NAMRATHA N, NADGIR S, KALE M, RATHOD R. Chromoblastomycosis due to Cladosporium carrionii J Lab Physicians [online] 2010, 2(1):47-48 [viewed 11 May 2014] Available from: doi:10.4103/0974-2727.66704

Investigations - for Diagnosis

Fact Explanation
Biopsy Examination of the biopsy specimens under the microscope enables identification of the organism which is the mainstay of the diagnosis. [3]
Fine-needle aspiration Allows obtaining samples for the microscopic examination. Hematoxylin-eosin and May-Grünwald-Giemsa staining are used. Three genera of disease causing organisma Nocardia, Actinomyces, and Streptomyces can be separately identified. Weekly acid fast gram-positive, beaded, branching filaments are seen in Nocardia. [1,2,3,4]
Culture Obtained tissue samples can be cultured in Löwenstein-Jensen media. Usually this takes a long time for the diagnosis. [1,4]
Serology Serological tests include immunodiffusion, counterimmunoelectrophoresis, enzyme-linked immunosorbent assay, and Western blot. [4]
X-ray films of involved bones [4] Periosteal thickening, lytic lesions, osteopenia are early radiological signs. Cortical thinning and disuse osteoporosis are also seen in X-ray films. [6]
CT scanning [4] CT and MRI are preferred imaging modalities in diagnosis of osteomyelitis. These investigations are highly sensitive but CT is considered superior in detecting the sequestra. Obtaining biopsy specimens from deeper sites can be done with CT guidance. [6]
MRI [4] Enable visualizing bone and soft-tissue involvement in actinomycetoma.
PET scan This is considered a useful investigation in assessment and diagnosis of chronic osteomyelitis. [5]
Ultrasonography [4,6] Aids in diagnosis of chronic osteomyelitis. Doppler studies will demonstrate the hyperemia around the site of involvement. [6]
References
  1. SAHA RAJDEEP, RIT KALIDAS. Actinomycetoma-recurrence after amputation. Ann Trop Med Public Health [online] 2013 December [viewed 11 May 2014] Available from: doi:10.4103/1755-6783.120988
  2. FERNANDES H, D'SOUZA CR, SHEKAR JC, MARLA NJ, SWETHADRI GK, NAIK R. Cytodiagnosis of actinomycetoma. Diagn Cytopathol [online] 2009 Jul, 37(7):506-8 [viewed 11 May 2014] Available from: doi:10.1002/dc.21040
  3. ANTUNES J, PACHECO D, TRAVASSOS R, SEQUEIRA H, FILIPE P, MARQUES MS. Actinomycetoma of the chest wall attributed to Nocardia nova after reconstructive surgery. Dermatol Online J [online] 2012 Jan 15, 18(1):4 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22301041
  4. JEREMY FARRAR, PETER HOTEZ, THOMAS JUNGHANSS, GAGANDEEP KANG, DAVID LALLOO, NICHOLAS J. WHITE. Manson's Tropical Diseases. Elsevier Health Sciences, Oct 26, 2013, pp. 1001.
  5. TERMAAT MF, RAIJMAKERS PG, SCHOLTEN HJ, BAKKER FC, PATKA P, HAARMAN HJ. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am [online] 2005 Nov, 87(11):2464-71 [viewed 11 May 2014] Available from: doi:10.2106/JBJS.D.02691
  6. PINEDA C, ESPINOSA R, PENA A. Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy Semin Plast Surg [online] 2009 May, 23(2):80-89 [viewed 11 May 2014] Available from: doi:10.1055/s-0029-1214160

Investigations - Followup

Fact Explanation
Sinography Allows visualization of sinus tract by injecting a radio-contrast material in to the sinus tract. This is important in deciding the best management option of sinuses. This can be combined with CT for better visualization. [1]
References
  1. PINEDA C, ESPINOSA R, PENA A. Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy Semin Plast Surg [online] 2009 May, 23(2):80-89 [viewed 11 May 2014] Available from: doi:10.1055/s-0029-1214160

Management - General Measures

Fact Explanation
Health education Farmers, soldiers, herdsmen and field labourers who work bare foot are at risk of acquiring the disease by traumatic inoculation of the organisms in to the skin. These people should be advised to wear boots and gloves to minimize the risk. [1]
References
  1. RATTANAVONG SAYAPHET, VONGTHONGCHIT SIVAY, BOUNPHAMALA KHAMHOU, VONGPHAKDY PHOUVONG, et al. Actinomycetoma in SE Asia: the first case from Laos and a review of the literature. Array [online] 2012 December [viewed 11 May 2014] Available from: doi:10.1186/1471-2334-12-349

Management - Specific Treatments

Fact Explanation
Antibiotic therapy Cotrimoxazole, dapsone, streptomycin, sulfadoxine-pyrimethamine, rifampicin and amoxicillin-clavulanic acid are effective in treatment. To prevent the occurrence of drug resistant organisms and for effective treatment combination of drugs is preferred over monotherapy. Cotrimoxazole can be combined with streptomycin, amikacin, dapsone and penicillin. Dapsone with ampicillin, amikacin or streptomycin can also be used for treatment. [1,2,3,4] Treatment is usually given in five weeks cycles and repeated when necessary to prevent relapses. [5]
Surgery Patients with chronic osteomyelitis benefit from surgical debridement under antibiotic coverage. [6]
References
  1. RAMAM M, BHAT R, GARG T, SHARMA VK, RAY R, SINGH MK, BANERJEE U, RAJENDRAN C. A modified two-step treatment for actinomycetoma. Indian J Dermatol Venereol Leprol [online] 2007 Jul-Aug, 73(4):235-9 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17675730
  2. MAHGOUB ES. Medical management of mycetoma. Bull World Health Organ [online] 1976, 54(3):303-10 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1088110
  3. KHATRI ML, AL-HALALI HM, FOUAD KHALID M, SAIF SA, VYAS MC. Mycetoma in Yemen: clinicoepidemiologic and histopathologic study. Int J Dermatol [online] 2002 Sep, 41(9):586-93 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12358829
  4. MAHAISAVARIYA P, CHAIPRASERT A, SIVAYATHORN A, KHEMNGERN S. Deep fungal and higher bacterial skin infections in Thailand: clinical manifestations and treatment regimens. Int J Dermatol [online] 1999 Apr, 38(4):279-84 [viewed 11 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10321944
  5. ARENAS ROBERTO, AMEEN MAHREEN. Giant grains of nocardia actinomycetoma. The Lancet Infectious Diseases [online] 2010 January [viewed 11 May 2014] Available from: doi:10.1016/S1473-3099(09)70347-0
  6. LEW DP, WALDVOGEL FA. Osteomyelitis. Lancet [online] 2004 Jul 24-30, 364(9431):369-79 [viewed 11 May 2014] Available from: doi:10.1016/S0140-6736(04)16727-5