| Abstract|| |
Mycetoma is a chronic granulomatous infection caused by fungi or bacteria, known as eumycetoma and actinomycetoma, respectively. Mycetoma commonly affects young males belonging to low socioeconomic strata, usually barefooted agricultural workers. It mainly affects lower and upper limbs presenting as a painless swelling with discharging sinus. Rarely, is it encountered in the intracranial location. The diagnosis relies on the clinical presentation and identification of the etiological agents within the tissue, by histology and special stains. It is important to specify the fungal or bacterial etiology, because the treatment of each is completely different. The management of such infections is challenging and should involve early diagnosis, the use of antibacterials or antifungals, and surgical removal of the lesion. To the best of our knowledge, only seven cases of intracranial mycetoma have been reported. The present case highlights the rarity of this lesion, thereby contributing to the existing literature and presenting its diagnostic implications.
Keywords: Actinomycetoma, eumycetoma, intracranial, mycetoma, temporal
|How to cite this article:|
Siraj F, Malik A, Shruti S, Shankar K B, Singh S. Cranial mycetoma: A rare case report with review of literature. J Global Infect Dis 2021;13:192-5
|How to cite this URL:|
Siraj F, Malik A, Shruti S, Shankar K B, Singh S. Cranial mycetoma: A rare case report with review of literature. J Global Infect Dis [serial online] 2021 [cited 2022 Jan 17];13:192-5. Available from: https://www.jgid.org/text.asp?2021/13/4/192/330917
| Introduction|| |
Mycetoma is a chronic, localized, slowly progressive, granulomatous infection. Based on its etiology, mycetoma is referred to as eumycetoma when the infection is caused by filamentous fungi and actinomycetoma when the infection is due to actinomycetes. Mycetoma commonly affects young adults in the age range of 20–40 years belonging to low socioeconomic strata; usually barefooted workers in the rural areas engaged in farming and rearing sheep. It shows a male predominance with a sex ratio of 3∶1. Repeated local minor trauma or penetrating injury provides a portal of entry for the organism. It mainly affects lower and upper limbs, although it may involve any part of the body. However, lesions of the scalp with involvement of cranial bones and brain are rare. It is important to specify the fungal or bacterial etiology, because treatment modalities differ. Managing such infections are still challenging and treatment should involve early diagnosis, the use of antibacterials or antifungals and surgical removal.
We report a case of cranial mycetoma in the brain parenchyma presenting as an abscess in a young male.
| Case Report|| |
An 18-year-old immunocompetent male presented with complaints of headache, fever, and an episode of convulsions. There was no neurological deficit on examination. Routine urine, stool, and blood analysis were normal. All laboratory parameters were within the normal limits. Furthermore, no scalp swelling or draining sinus was evident. NCCT head revealed an ill marginated hypodense lesion in the temporal lobe with contiguous peri-lesional odema [Figure 1]. Based on clinical and preoperative radiological findings, a provisional diagnosis of brain abscess was made. The lesion was excised and sent for the histopathological examination. Grossly multiple gray black tissue fragments were received, cut sections of which showed black granules. The postoperative period was uneventful.
|Figure 1: Coronal noncontrast computed tomography scan shows an ill-marginated hypodense lesion (yellow star) in the left temporal lobe with contiguous edema|
Click here to view
Histopathological examination showed predominantly areas of acute and chronic inflammation. At places, colonies of compact aggregates of thin filamentous structures surrounded by dense inflammatory infiltrate were seen [Figure 2]. The center of the abscess revealed granules with central pale color and Splender − Hopple phenomenon. Morphological diagnosis of mycetoma was made, and special stains were performed. Mycetoma colonies showed positivity for Periodic acid Schiff [Figure 3]a and Gomori-methenamine silver [Figure 3]b. Grams stain was done to differentiate between actinomycetes and eumycetes, and it was negative. Tissue was not sent for culture. The final diagnosis of eumycetoma in the temporal region was rendered.
|Figure 2: Photomicrograph showing granule with pale center and Splender-Hopple phenomenon amidst suppurative inflammation (H and E, ×200)|
Click here to view
|Figure 3: (a) Filamentous hyphae in the center of the granule periodic acid Schiff (PAS, ×200). (b) Filamentous hyphae in the center of the granule in the periphery-GMS stain (GMS, ×400)|
Click here to view
| Discussion|| |
“Madura foot” was first described by Dr. John Gill in 1842 in a dispensary report of the Madras Medical Service of the British Army in India. Pinoy in 1913 recognized the possibility of classifying cases of mycetoma by grouping the causative organisms. It is endemic in many tropical and subtropical countries such as India, Pakistan, and parts of Africa.
Young adult males in the age range of 20–40 years are more frequently affected. Farmers, workers, and students are affected most, but no occupation is exempted. In general, the exposed areas of the body that include hands and feet are more frequently involved with mycetoma. The lesions are usually restricted to the site of entry of organisms for few weeks leading to swelling and nodule formation, which after few months results in discharging sinuses, having the presence of grains, which are pathognomic. Histologically, the organisms of actinomycetoma display Splendore − Hoeppli reaction which is a central matted appearance surrounded by a peripheral deposition of eosinophilic infiltrate.
The demonstration of the organisms by Gram staining helps in species identification. The organisms found in actinomycetoma are 1 μ thin, branching filaments which are Gram-positive and acid-fast, whereas the granules of eumycetoma are Gram-negative, septate hyphae, 4–5 μ thick. Although culture is the gold standard for the diagnosis of eumycetoma, it takes a long time with false-positive results due to contamination of sample.
Craniocerebral involvement is a very uncommon phenomenon, and only seven cases are reported in the medical literature till date, excluding the index case [Table 1]. Five patients were male and two were female. The average age among all the reported cases was 24.3 years. Our patient was an 18-year-old immunocompetent male. Unlike others, our patient had no typical history of swelling or discharging sinuses. Furthermore, there was no calvarial or dural involvement. The lesion was exclusively within the temporal lobe.
In 1950, Hickey et al. reported three patients of cranial eumycetoma without penetration of the dura. In 1975, the first reported case of mycetoma involving the cerebral cortex in the English literature was reported by Natarajan et al. The patient had a pyogenic brain abscess at the site of the cranial mycetoma. In 2007, a case of cerebellopontine angle eumycetoma in a young female was reported. In 2008, Beeram et al. described a case of maduromycetoma involving the left parietal cortex, bone, and subcutaneous tissue in an 18-year-old young male farm laborer who presented with left parietal scalp swelling that had progressed into a relentlessly discharging sinus. In 2010, Maheshwari et al. reported a case of Madurella infection of the paranasal sinuses that extended into the intracranial compartment. Rao et al. in 2015 reported a patient with eumycotic mycetoma affecting the scalp, skull bone, Dura and underlying brain parenchyma presenting with atypical features.
Early diagnosis remains critical for treatment, reducing the associated morbidity with this condition. Surgical excision of the lesion is the mainstay of treatment as response to medical therapy alone is not very effective and associated with late relapses. It is also important to initiate the correct treatment with antibacterials or antifungals based on the species for optimal response. Our patient was started on anti-fungal therapy and is doing well at 6 months' follow-up.
| Conclusion|| |
Cerebral mycetoma is a rare entity. Only seven cases have been reported in the literature. Because of the chronic nature of disease, it is often diagnosed at an advanced stage. Hence, there is a need for a correct and prompt diagnosis after meticulous clinical examination and histopathology, along with special stains for species identification. It is important to distinguish between fungal or bacterial etiology as the treatment is different for each entity. Early diagnosis followed by medical therapy combined with surgical debridement is the treatment of choice, although long-term follow-up is necessary.<--,,-->
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Research quality and ethics statement
The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pollack IF, Pang D, Schuit KE. Chronic granulomatous disease with cranial fungal osteomyelitis and epidural abscess. Case report. J Neurosurg 1987;67:132-6.
Bonifaz A, Tirado-Sánchez A, Calderón L, Saúl A, Araiza J, Hernández M, et al
. Mycetoma: Experience of 482 cases in a single center in Mexico. PLoS Negl Trop Dis 2014;8:e3102.
Desai SC, Pardanani DS, Sreedevi N, Mehta RS. Studies on mycetoma. Clinical, mycological, histological and radiological studies on 40 cases of mycetoma with a note on its history and epidemiology in India. Indian J Surg 1970;32:427-47.
Gooptu S, Ali I, Singh G, Mishra RN. Mycetoma foot. J Family Community Med 2013;20:136-8.
Natarajan M, Balakrishnan D, Muthu AK, Arumugham K. Maduromycosis of the brain. Case report. J Neurosurg 1975;42:229-31.
Rao KV, Praveen A, Megha S, Sundaram C, Purohith AK. Atypical craniocerebral eumycetoma: A case report and review of literature. Asian J Neurosurg 2015;10:56.
] [Full text]
Mohanty PK, Ambekar VA, Deodhar LP, Ranade RR, Mehta VR. Nocardiabrasiliensis-mycetoma – (A case report). J Postgrad Med 1982;28:179.
Vyas MC, Arora HL, Joshi KR. Histopathological identification of various causal species of mycetoma prevalent in North-west Rajasthan (bikaner Region). Indian J Dermatol Venereol Leprol 1985;51:76-9.
] [Full text]
Pilsczek FH, Augenbraun M. Mycetoma fungal infection: Multiple organisms as colonizers or pathogens? Rev Soc Bras Med Trop 2007;40:463-5.
Fahal AH. Mycetoma: A thorn in the flesh. Trans R Soc Trop Med Hyg 2004;98:3-11.
Kiran NA, Kasliwal MK, Suri A, Sharma BS, Suri V, Mridha AR, et al
.Eumycetoma presenting as a cerebellopontine angle mass lesion. Clin Neurol Neurosurg 2007;109:516-9.
Beeram V, Challa S, Vannemreddy P. Cerebral mycetoma with cranial osteomyelitis. J Neurosurg Pediatr 2008;1:493-5.
Maheshwari S, Figueiredo A, Narurkar S, Goel A. Madurella mycetoma
– A rare case with cranial extension. World Neurosurg 2010;73:69-71.
Ahmed M, Sureka J, Chacko G, Eapen A. MRI findings in cranial eumycetoma. Indian J Radiol Imaging 2011;21:261-3.
] [Full text]
Goel RS, Kataria R, Sinha VD, Gupta A, Singh S, Jain A. Craniocerebral maduromycosis: Case report. J Neurosurg Pediatr 2012;10:67-70.
Behera BR, Mishra S, Dhir MK, Panda RN, Samantaray S. “Madura Head” – A rare case of craniocerebral maduromycosis. Indian J Neurosurg 2018;7:159-63.
Dr. Swati Singh
Department of Pathology, ICMR National Institute of Pathology, Safdarjung Hospital Campus, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]