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© WHO/Cristopher Michel
People living in or travelling to endemic areas should be advised not to walk barefoot, as footwear and clothing in general can protect against puncture wounds.
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Mycetoma

21 June 2019

Key facts

  • Mycetoma is a chronic, progressively destructive infectious disease of the subcutaneous tissues, affecting skin, muscle and bone.
  • Mycetoma can be caused by different species of microorganisms, but almost always by bacteria or fungus.
  • Mycetoma occurs in tropical and subtropical environments characterized by short rainy seasons and prolonged dry seasons that favour the growth of thorny bushes.
  • Global burden is not known, but the disease is endemic; it has been reported from countries in Africa, Asia, Europe and Latin America.
  • Mycetoma has numerous adverse medical, health and socioeconomic consequences for patients, communities and health services in affected areas.
  • People living in or travelling to endemic areas should be advised not to walk barefoot, as footwear and clothing in general can protect against puncture wounds.

66顺彩票appMycetoma is a chronic disease usually of the foot but any part of the body can be affected. Infection is most probably acquired by traumatic inoculation of certain fungi or ‎bacteria into the subcutaneous tissue.

The disease commonly affects young adults, mostly males aged between 15 and 30 years in developing countries. People of low socioeconomic status and manual workers such as agriculturalists, labourers and herdsmen are the worst affected.

Mycetoma has numerous adverse medical, health and socioeconomic impacts on patients, communities and health authorities. Accurate data on its incidence and prevalence are not available. However, early detection and treatment are important to reduce morbidity and improve treatment outcomes.

Mycetoma was first reported in the mid-19th century in Madurai, India, and hence was initially called Madura foot.

Distribution

The causative organisms of mycetoma are distributed worldwide but are endemic in tropical and subtropical areas in the so called 'Mycetoma belt', which includes the Bolivarian Republic of Venezuela, Chad, Ethiopia, India, Mauritania, Mexico, Senegal, Somalia, Sudan, Thailand, and Yemen.

Transmission

66顺彩票appTransmission occurs when the causative organism enters the body through minor trauma or a penetrating injury, commonly thorn pricks. There is a clear association between mycetoma and individuals who walk barefooted and are manual workers.

Clinical characteristics

66顺彩票appMycetoma is characterized by a combination of painless ‎subcutaneous mass, multiple sinuses and discharge ‎containing grains. It usually ‎spreads to involve the skin, deep structures and bone, resulting in ‎destruction, ‎deformity and loss of function, which may be fatal. ‎Mycetoma commonly ‎involves the extremities, back and gluteal region but any other part of the body can be affected.‎ Given its slow progression, painless nature, lack of awareness, and scarcity of medical and health facilities in endemic areas, many patients present late with advanced infection where amputation may be the only available treatment. Secondary bacterial infection is common, and that may cause increased pain, disability and fatal septicaemia (severe infections involving the entire human system), if untreated. Infection is not transmitted from human to human.

Diagnosis

The diagnosis of mycetoma is based on clinical presentation and identification of the causative organisms which can be detected by directly examining the grains that are discharged by the sinuses. The samples can be obtained from any open discharging sinus by Fine Needle Aspiration (FNA) or surgical biopsy. Although grains microscopy is helpful in detecting the causative organism, it is important to further identify these by culture but even then misclassification occurs. Identification by Polymerase chain reaction (PCR) is the most reliable method but has high cost and lacks standardized techniques. There is no serological diagnostic test. Imaging techniques including X-rays, ultrasound, magnetic resonance and computer tomography can be used to assess the extent of lesions and planning the clinical management.

Treatment

66顺彩票appThe treatment depends on the causative organisms. For the bacterial type, it is a combination antibiotics whereas for fungal type it is combined antifungal drugs and surgery. The treatment is frequently unsatisfactory, has many side effects, expensive and not available in endemic areas.

Prevention & Control

Mycetoma is not a notifiable disease (a disease required by law to be reported) and global surveillance system is being developed. There are no control programmes for mycetoma yet, except for Sudan. Preventing infection is difficult, but people living in or travelling to endemic areas should be advised not to walk barefooted.

WHO and global response

To build national capacities on mycetoma, the Government of Sudan and WHO convened the First International 66顺彩票app Workshop on Mycetoma in Khartoum on 10–14 February 2019. Drawing on the expertise of the Mycetoma Research Centre in Khartoum, the workshop - attended by approximately 50 health staff from many mycetoma-endemic countries - provided a unique opportunity to share experiences and standardize practices relating to diagnosis, treatment and surveillance.

66顺彩票appThe workshop was followed by the Sixth International Conference on Mycetoma in Khartoum on 15-17 February 2019. The Conference adopted the ‘Khartoum Call for Action on mycetoma’ which calls on a wide range of actors to take specific public-health and policy measures to address the burden of mycetoma

Opportunities

Elaborating a public health strategy for the prevention and control of Mycetoma requires collection of epidemiological data on burden of disease, investment in research and product development, so that cost-effective prevention, diagnosis, early treatment and case management can be practiced in low-resource settings.

At present, active case-finding with early diagnosis and treatment with currently available tools is the most appropriate approach for lessening Mycetoma's disease morbidity and disability. However, important public health actions are required to tackling the burden of mycetoma. Some of these include:

  • including mycetoma in national surveillance systems and establishing a registry in affected countries;
  • Integrating mycetoma detection within the skin-NTDs approach to enhance early detection
  • improving access to diagnostics and medicines and refinement of protocols for case-management;
  • strengthening preventive measures (e.g. wearing shoes) to decrease incidence;
  • reinforcing awareness among affected communities and building capacities of health staff.

66顺彩票appCurrently, the Drugs for Neglected Diseases initiative (DNDi) and other partners are investigating the safety and efficacy of fosravuconazole in treating eumycetoma in Sudan. In addition to an expected higher cure rate, if successful, the adoption of the results of this treatment would allow for a shorter therapeutic protocol, boosting compliance with treatment and saving financial resources.

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