Unravelling the challenges of mycetoma: a case series highlighting diagnostic dilemmas and therapeutic triumphs

Mycetoma is a chronic suppurative granulomatous infection of the deep dermis and subcutaneous tissue prevalent in tropical and subtropical regions and is caused by filamentous aerobic bacteria (actinomycetoma) or true fungi (eumycetoma), representing 60% and 40% of cases worldwide, respectively. The causative organism enters into the subcutaneous tissue, usually of the foot, from contaminated soil or vegetative material through inoculation from a thorn prick, or repeated trauma. It commonly affects men, farmers and field workers. Differentiating eumycetoma from actinomycetoma can be challenging but is required before starting prolonged treatment. One of our patients presented with lesions on the thigh and in a sporotrichoid pattern that is atypical, while the other two patients were treated with antifungal medication for eumycetoma for years without proper investigation and improvement. Early diagnosis of actinomycetoma is mandatory to prevent tissue destruction, bone invasion and ultimate loss of function by proper investigative workup, histopathology and direct microscopy of discharge. We here report three cases of actinomycetoma with clinical and microbiology profiles treated successfully with tablets of trimethoprim-sulfamethoxazoleand amoxicillin-clavulanic acid along with folic acid as proposed by the Cochrane systemic review protocol 2018.