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We report a rare case of actinomycetoma of the foot (madura foot) due to Actinomadura madurae in a patient living in a Temperate Zone country. Plain radiographs and MRI imaging were useful in establishing the diagnosis.

Madurella mycetomatis is the most common fungal agent causing eumycetoma. The commonest clinical presentation of the infection is the appearance of multiple sinuses with discharge of grains, which are the colonies of the fungus. It is an emerging fungal infection among transplant recipients and has not been reported following stem cell transplantation. We report here a case of aplastic anemia who developed madura foot, caused by Madurella mycetomatis, following allogenic peripheral blood stem cell transplantation. The diagnosis was made by the examination of discharged black grains under microscope which reavaled presence of septate hyphae and the culture of the discharged granules grew Madurella mycetomatis. The patient was treated with voriconazole followed by excision of the lesion, which resulted in complete recovery. Considering the increasing number of patients undergoing stem cell transplantation for various hematological diseases, the implications of this fungal infection should be recognized as delay in treatment may be life-threatening.

With the increased movement of the world population, familiarity with the clinical picture of the Madura foot is of growing importance beyond its original endemic areas. The characteristic triad of symptoms consists of indurated swelling, multiple sinus tracts with purulent discharge filled with grains and localization at the foot. An increasing number of new etiologic agents are recognized today. For a better choice of therapy an adequate diagnostic procedure is essential; a deep biopsy for histology appears to give a more substantial contribution to identification of the causal organism than culture. The treatment which should be started early is at first essentially a drug treatment. However, in spite of high expectations with regard to new antimycotic drugs, amputation or disarticulation is often inevitable even today, particularly when the lesion is caused by Eumycetes. We present a case of eumycotic mycetoma with extensive involvement of foot for which a Boyd’s amputation was done and treated with antifungal therapy with no recurrence.

Maduramycosis has been considered practically synonymous with so-called Madura foot, a term coined by the natives of India in the vicinity of Madura, one of the districts in which the disease is endemic. In Bocarro's (1893) series 1 of 100 cases, 93 involved the foot, 3 the hand and 2 the leg and trunk, respectively. Fungous infections are widely distributed throughout tropical and subtropical zones. Maduramycosis is occasionally seen in Africa, Europe, South America, Mexico and the United States, chiefly in Texas. However, of the 38 cases which have been reported in this country, only 11 (Downing and Conant, 2 [1945]) can be classified as maduramycosis as proved by culture of the organism. Our case belongs in the latter category. REPORT OF CASE A. T., a boy aged 8 years, was born and reared in Placitas, N. Mex., and had never been out of his native state. He was admitted

We report here an unusual pathology in a 1,500-year-old skeleton recovered from Bet Guvrin, Israel. The pathological changes in the lower extremities and the diagnostic difficulties are presented. We attribute this condition to Madura foot, found primarily in tropical and subtropical regions, although other diagnoses are possible and are noted. We discuss its appearance in the region in light of the historical context.

Summary ‘Madura foot' or mycetoma is a chronic granulomatous soft-tissue infection, caused by either true fungi (eumycetoma) or Gram-positive aerobic bacteria (actinomycetoma). The infection is endemic to equatorial, tropical or sub-tropical regions. However, sporadic cases have been reported in the Western world mostly in the migrant population. The disease follows a slow progression from the time of traumatic inoculation to presentation of symptoms, characterised by a triad of chronic indurated swelling, draining sinuses and discharging granules. The granules are diagnostic as they represent collections of fungal hyphae or bacterial filaments. We present a case of a 4-year eumycetoma of the left foot in a 16-year-old Somalian girl, resident in the UK for over a year. She underwent aggressive surgical debridement with a 6-month course of anti-fungal medication. We emphasise the need for suspicion of this rare dermatosis, in view of the increasing immigrant population.

The literature states that proper management of Madura foot strongly depends on accurate identification of the causative organism. We describe the case of a patient with Madura foot who was diagnosed with eumycetoma after the dot-in-circle sign, which has been previously reported in regard to magnetic resonance images of this lesion, was observed on both ultrasound and magnetic resonance images. Level of Clinical Evidence: 4

In this case presentation, the diagnosis was based solely on the histopathologic examination of tissue taken at the time of the first surgery. Subsequent cultures did not reveal any growth of organisms that would cause Madura foot. The patient must be monitored periodically, for it is rare that such an infection is cured with surgery other than amputation.

Madura foot or mycetoma is endemic in many developing countries. It is occasionally seen within the United States due to increasing international travel but it may sometimes be acquired within US soil. Herein, we present a case of a patient with a diagnosis of mycetoma acquired through trauma to the foot. In addition, we discuss the epidemiology, etiological agents, clinical presentation, diagnosis, and treatment of mycetomas. Clinicians need to recognize mycetoma early and institute treatment promptly to reduce the substantial morbidity associated with this devastating infection.

We describe a patient with mycetoma or Madura foot, in which histopathological stains of the bone and surface cultures suggested three different organisms including Nocardia species as the cause. Criteria for the diagnosis of the organisms, differentiation between colonizer and pathogen, and significance of mixed infections are discussed. Descrevemos um paciente com micetoma ou maduromicose de pé, no que colorações histopatológicos de osso e de culturas superficiais sugeriram três organismos diferentes, incluindo espécies de Nocardia como causador. Os critérios de diagnóstico dos organismos, a diferenciação entre colonizador e patógeno, e a significância das infecções mistas são discutidos.

George Ballingall qualified with the Licentiate Diploma of the Royal College of Surgeons of Edinburgh in December 1805 and joined the Army Medical Department in May of the following year, spending the majority of his army career in India. He also served in Java. Eventually he was awarded his MD Edinburgh degree in 1819, and the FRCS Edinburgh and Fellowship of the Royal Society of Edinburgh during the following year. He was appointed to the Regius Chair of Military Surgery in the University of Edinburgh in November 1822, succeeding John Thomson, its first holder, and he held this post until his death in December 1855. Ballingall was the first to describe ‘Madura Foot’, sometimes called ‘Ballingall's disease.’ In 1833 he published Outlines of Military Surgery which ran to five editions. He was appointed Surgeon-Extraordinary to the King (William IV) and Surgeon to the Queen. He also established a fine Museum Collection to complement his Lecture Course. Throughout his teaching career, he campaigned vigorously in support of military medical educational reform. One of his sons and several grandchildren also served in the medical service of the army or in that of the Honourable East India Company.

One rare and peculiar result of repeated minor trauma to the leg is Madura foot. Caused by fungi or fungus-like bacteria, Madura foot is found mainly in the tropics. A report of a classic case with chronic indurated swelling involving the leg and a discharge of yellowish granules is presented. The case is reported to highlight the fact that though Maduramycosis needs prolonged intensive antibacterial chemotherapy, even extensive disease can be successfully managed with conservative therapy.

We present a case of mycetoma by Actinomadura spp. on the foot of an Albanian young man arrived to our observation approximately 5 years after the first clinical manifestations (hard tumefaction, slightly painful upon weight-bearing and palpation and cutaneous fistulas that discharged an abundant granulomatous secretion). Direct microscopic analysis and culture of the white-yellowish grains included Gram staining, which showed extensively branched Gram-positive hyphae less than 1 mm in diameter, allowing to make a diagnosis of Actinomycetoma. Since Actinomycetoma is sensitive to drug treatment, the patient was given trimethoprim-sulfamethoxazole and amikacin twice daily for 45 days. After six months of chemotherapy, the patient's general condition improved, the swelling is slightly diminished and grain extrusion has ceased. The patient has been able to resume ambulation with normal footwear. Given the absence of liver and kidney functional alterations, the patient is scheduled to continue pharmacological treatment with trimethoprim-sulfamethoxazole.

Mycetomas are chronic, subcutaneous infections characterized by a clinical triad of chronic induration, draining sinuses, and discharge of granules. The granules are composed of colonies of either actinomycotic bacteria or eumycotic fungi. The infection develops after traumatic inoculation with contaminated soil and progresses to adjacent tissues or bone. The foot, hand, and lower-leg regions are the most commonly affected areas. Treatment can be difficult and includes surgical debridement with prolonged antibiotic or antifungal treatment. Mycetomas are primarily found in tropical and subtropical areas of the world and are relatively rare in the United States. A case of indigenously obtained actinomycoses that was successfully treated with surgical resection and long-term antibiotic therapy is presented. This case is unique because of the rarity of contracting this type of infection in the United States. Mycetomas have been reported in southern states, but there are no reported cases of obtaining this pathogen in Michigan. This case stresses the need for clinical suspicion of this rare dermatosis, especially considering the increase in immigration to the United States.

Maduromycosis is a chronic granulomatous condition caused by fungal infection and is rarely encountered in Europe. To our knowledge, this is the first report of a case of maduromycosis affecting the chest wall in the United Kingdom. Conservative excision and drainage of the lesion combined with ketoconazole treatment in a dose 400 mg daily for several months failed to cure the condition. However, radical excision of the lesion combined with myoplastic repair of the defect in the chest wall eradicated the disease. Maduromycosis can occur in the chest wall and should be suspected in the immigrant population from tropical and subtropical areas. We recommend radical resection of similar lesions, combined with prolonged treatment with an antifungal agent e.g. ketoconazole when the causative organism is madurella mycetomis.

Comparatively few cases of mycetoma ("Madura foot") have been reported in Australia, and only one caused by Nocardia brasiliensis. We report two Aboriginal women from remote communities in central Australia who presented with longstanding mycetomas caused by this organism. Difficulties in diagnosis substantially delayed commencement of effective treatment, illustrating the need to consider this condition in chronic suppurative skin infection.

Mycetoma pedis or Madura foot is rare in central Europe but has a wide distribution in the tropics. In roentgendiagnostic there are a destruction of the cortical margin and lytic zones in the spongiosa. Older bone manifestations show sclerosis. Periosteal reaction provokes spicules and only seldom "onion peel" patterns.

A total of 29 patients with mycologically and histopathologically proven mycetomas were examined for radiological manifestations from April 1984 to March 1996. Twenty cases were actinomycotic mycetomas, while nine were maduromycotic mycetomas. Plain x-rays of the regions of interest were taken in all the cases and CT scan was performed on five selected cases to compare the findings. Soft tissue changes were observed in all the examined cases, while bony changes were observed in 16 (55.7%). CT scan is useful for showing soft tissue changes, erosion and destruction of bone in cases with an early infection only, which cannot be demonstrated in plain radiographs.

Madura foot or mycetoma is a chronic granulomatous disease characterized by localized infection of subcutaneous tissues by actinomycetes or fungi. The recurrence rate for the disease if treated inadequately is very high. Recurrence presents with swelling and multiple discharging sinuses. This is an unusual presentation of the disease without discharging sinuses which is probable the first report of this kind in the literature. A 34 year old, male, presented with the painless, progressive swellings over right foot since 4 years. No sinuses or discharge could be found on skin surface. The postoperative recurrence rate is very high, and this can be local or distant at the regional lymph nodes. This could be due to the disease biology and behavior or inadequate surgical excision. Usually it presents with multiple sinus tracts, and granule. We reported a case with classical absence of sinus tracts in recurrent actinomycosis.

Mycetoma, also known as Madura foot, is a rare soft-tissue granulomatous infection caused by Actinomyces or true fungi. The MRI “dot-in-circle” sign has been described as a characteristic finding of mycetoma. This sign represents spherical T2 bright masses containing central and intervening low-signal-intensity foci. However, other soft-tissue masses can have similar appearances. We present a case of a Madura foot that was erroneously given the imaging diagnosis of soft-tissue hemangioma due to the presence of serpiginous enhancing masses with the “dot-in-circle” sign (believed to be due to phleboliths).

Three-phase Tc-99m MDP bone imaging of the feet was performed in a 69-year-old woman, a retired missionary who had worked in India and Africa. She was followed in the tropical disease clinic at our institution for a draining sinus from the dorsum of her right foot, which was cultured and found to be positive for Madurella mycetomatis. The three-phase bone scan, performed to assess disease activity and rule out underlying fractures before therapy was begun, showed marked hyperemia to the right forefoot on the anterior and plantar projections. Delayed images showed increased activity in the medial aspect of the right foot that corresponded to the destructive changes seen on the plain radiographs of the right foot. The scintigraphic appearance was more consistent with infection rather than an acute fracture.

Two cases of Madura foot which originated in the Middle East are described. This so-called maduramycosis is a chronic progressive infection caused by thread fungi or actinomycetes. The diagnosis is confirmed when the grains of mycetoplaits are demonstrated in the discharge from a sinus. Clinical findings and treatment are discussed. Medical treatment may be needed for several months, but operation is indicated for infections caused by the true fungi (eumycetoma).

In an attempt to produce an animal model of a mycetoma (Madura foot) Madurella mycetomi was inoculated on 3 occasions into a monkey's paw. Groups of mice were inoculated once in the footpad and treated with anti-mouse-lymphocytic serum, cortisone acetate and whole body X-irradiation respectively; half of the groups received the fungus suspended in saline and in half the fungus was emulsified in Freund's adjuvant. An attempt was also made to produce intraperitoneal grains of M. mycetomi in mice.The monkey developed a transient lesion. The footpad inoculations in the mice caused inflammatory swelling which was severe and persistent in the animals which received the fungus emulsified in Freund's adjuvant but grains were not produced.

Madura foot caused by a new species of Cephalosporium is described. It develops black granules in the host, and in artificial culture forms greyish-white to tan coloured colonies, with fasciculate aerial hyphae in the centre. It differs from C. madurae and C. granulomatis in the size of conidia and is designated C. infestans.

Der Begriff des „Mycetoms“ wurde 1861 vonCarter eingefuhrt fur ein Krankheitsbild, welches unter der Bezeichnung „Madurafus“ vor allem in Indien bekannt und beschrieben worden war. Die durch verschiedeneErreger wie Actinomyceten, Nocardien, Streptomyceten und echten Pilze hervorgerufenen chronischen Entzundungen konnen sich in jedem einer auseren Verletzung zuganglichen Korperteil manifestieren. Im Gegensatz zur Vielzahl und Mannigfaltigkeit der Erreger ist das Krankheitsbild klinisch-anatomisch recht einheitlich. Mycetome sind in Europa auserordentlich selten, wahrend sie in anderen Erdteilen, zum Beispiel im Sudan, endemisch vorkommen. Arzte-Equipen, welche fur das Internationale Komitee des Roten Kreuzes in Nordyemen ein Feldspital betrieben, lernten dort diese Krankkeit naher kennen. Der vorliegende Bericht gibt auf Grund der gewonnenen Erfahrung und unter Auswertung der wichtigeren und grundlegenden Arbeiten der Literatur einen Uberblick uber das Krankheitsbild der Mycetome. Die Mycetome verhalten sich in bezug auf Klinik und Therapie ahnlich wie maligne Tumoren. Die Therapie ist vorwiegend chirurgisch, sie besteht in der Amputation oder Excision im Gesunden. Vereinzelte Mitteilungen in jungster Zeit lassen hoffen, das bald auch eine medikamentose Therapie zur Heilung fuhren kann. Der Bericht weist auf die Zusammenhange hin zwischen der Haufigkeit der Erkrankung sowie der Erregerarten mit Klimafaktoren. Die klinischen, histologischen und mykologischen Unterschiede der Erreger werden beschrieben. Auf 7 von 11 gesehenen Krankheitsbilder wird naher eingegangen und dabei auf Grund des klinischen, rontgenologischen und histologischen Aspekts auf Streptomyces madurae und Streptomyces somaliensis als Erreger geschlossen. In einem Fall wird das Vorliegen von Streptomyces pelletieri vermutet. Mykologische Studien konnten aus praktischen Grunden nicht durchgefuhrt werden. Der Bericht bestatigt die Vermutung mehrerer Autoren, das die Mycetome nicht nur in einer quer durch Afrika verlaufenden Zone zwischen dem 15. und 20. Breitengrad gehauft vorkommen, sondern unter gleichen klimatischen Gegebenheiten auch in anderen Gebieten dieser Breitenlage.

The genus Cephalosporium described by Corda in 1842 has attracted considerable attention in recent years following the world-wide search for new antibiotics. Some of the species like Emericellopsis salmosynnemata Grosklags and Swift (2) produce antibiotic Synnematin-B. Other species are soil inhabitants, plant pathogens, or parasites on insects. In India several plant parasites are recorded such as C. eichorniae Padwick (7), C. zonatum Sawada (5) and C. fici Tims & Olive (4). Among the soil fungi C. acremonium Cda. (10) and C. roseogriseum Saksena (9) are recorded from India. C. madurae Padhye, Sukapure & Thirum. (6) and C. infestans Gaind & Thirum. (1) were shown to be incitants of madura foot in India producing black granules. A few species like C. lecanii Zimm. are parasitic on scale insects. In the present investigation Cephalosporium species isolated from soil were studied with reference to their morphology, cultural characters, identity and antibiotic production.

Madura foot incited by a new species ofCephalosporium is presented. Case history, clinical symptoms and morphological features of the new pathogen are discussed. Comparative studies with the previously reported species indicate that the species isolated is an undescribed one and the nameCephalosporium madurae is proposed for it.

HISTORY Sixty years ago (in 1877), Bollinger and his botanist colleague Harz discovered and named the ray fungus, or Actinomyces bovis, the cause of a disease of cattle known as lumpy jaw, characterized by the formation of a hard, boardlike swelling of the tongue or a fusiform enlargement of the jaw. In the following year Israel described a similar mycotic disease in man, and in 1879 Ponfick suggested that the two diseases were identical. However, in 1891 Bostroem demonstrated the aerobic peculiarity of the organism found in 7 cases of actinomycosis in cattle, and coincidentally Israel and Wolff called attention to the anaerobic charcateristic of a similar branching organism isolated in 2 cases of the disease in man. Organisms resembling Actinomyces have been isolated in several diseases. The fungus causing Madura foot, reported by Carter in 1874, was cultivated by Vincent in 1894 and shown to be an anaeobic branching