CASE MANAGEMENT

Presentor: Dr. Shayne CallejaModerator: Dr. Francia BalatanResource Speakers:

Dr. Joey RanolaDr. Willbur Belleca

MADURA FOOT

GENERAL OBJECTIVE

• To present a case of a rare chronic foot infection.

SPECIFIC OBJECTIVES• To discuss the clinical presentation of Madura

foot that differentiates it from other foot infections

• To show the characteristic radiological findings as well as macroscopic and microscopic presentation of Madura foot

• To present the diagnostic and treatment approach in patients with Madura foot

• To discuss the role of surgical intervention in the management of Madura foot

GENERAL DATA• CW.V., • 37/M, • Filipino, single, • Roman Catholic, • presently residing at St. Paul Subdivision, Palestina, Pili,

Camarines Sur, • Admitted on November 28, 2012

CHIEF COMPLAINT:

• Infected wound, left foot

HISTORY OF PRESENT ILLNESS• 36 MONTHS PTA

• (+) insect bite at the dorsum of his left foot swollen

• Consultation was done and he was given several antibiotics.

• advised wound debridement financial constraints opted for medical management and took different antibiotics x 1 year swelling subsided

HISTORY OF PRESENT ILLNESS• 12 months PTA,

• left foot swelling recurred. • Consulted an herbolaryo herbal medicines

including banaba leaves, malunggay leaves, guava leaves and tubo temporarily relieved

• consulted a private MD Ciprofloxacin, Naproxen Na and Omeprazole

HISTORY OF PRESENT ILLNESS• 9 months PTA,

• (+) swelling of his left foot with intermittent discharge of pus,

• consulted an Infectious Disease specialist anti-koch’s meds started jaundice anti-Koch’s discontinued

given Godex, anti-kochs resumed in separate tablets

Liver function tests: normal

HISTORY OF PRESENT ILLNESS• 4 months PTA,

• (+) painless subcutaneous nodules and sinus tracts with yellowish exudates

• sought second opinion with an orthopedic surgeon• CT scan of the left foot: osteomyelitis• Advised I and D and possible amputation

refused surgical management• returned to the ID specialist: anti-koch’s

medications continued

HISTORY OF PRESENT ILLNESS• 1 month PTA

• (+) painless subcutaneous nodules and sinus tracts with yellowish exudates

• Cloxacillin sodium was added to his anti-koch’s regimen.

HISTORY OF PRESENT ILLNESS• 1 week PTA,

• several subcutaneous nodules erupting with sinus tracts containing yellowish exudates

• (+) Pain and swelling took Ibuprofen and Mefenamic acid

• (+) difficulty in ambulation• (+) fever relieved by paracetamol• Wound dressing with Terramycin ointment.

HISTORY OF PRESENT ILLNESS• Few hours PTA,

• (+) pain, swelling and eruption of several subcutaneous nodules with sinus tracts

ADMITTED

PAST MEDICAL HISTORY:

• (-) Hypertension, • (-) Diabetes Mellitus, • (-) PTB, • (-) Bronchial Asthma • (-) History of travel to endemic places

PERSONAL/SOCIAL HISTORY:

• Patient is a veterinarian. • A non-smoker, non-alcoholic beverage drinker.

FAMILY HISTORY:

• Unremarkable

ROS:

(-) Weight Loss (-) Anorexia(-) Cough/colds (-) Dyspnea (-) Easy Fatigability

(-) chest pain (-) Orthopnea(-) Changes in bowel habits (-) melena (-)

hematochezia (-) polyuria (-) polydypsia (-) polyphagia(-) limitation of movement

PHYSICAL EXAMINATION

Patient is conscious, coherent, not in cardiorespiratory distressBP: 90/60 PR: 60 RR: 19 T: 36.3

Pale palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no nasoaural discharge, no palpable cervicolymphadenopathy, (+) inguinal lymphadenpathy

Symmetrical chest expansion, no retraction, no crackles, no wheezes

Adynamic precordium, normal rate, regular rhythm, goodS1 and S2, apex beat at 5th ICS LMCL, no murmur

PHYSICAL EXAMINATION

Abdomen is flabby, normoactive bowel sounds, (+) direct tenderness on hypogastric area, (+) CVA tenderness, bilateral; no organomegaly, no guarding

Swelling of the left foot, with hyperpigmentation and formation of abscess and sinus tracts with yellowish discharge/granules embedded in a shell-like substance.

DORSUM OF LEFT FOOT

DORSUM OF LEFT FOOT

PLANTAR ASPECT OF LEFT FOOT

PHYSICAL EXAMINATIONNeuro Exam:

Patient is oriented to time, place and person.I – Can smell coffeeII, III – Pupils equally reactive to lightIII, IV, VI – Extraocular movements intactV - Corneal Reflex intactVII Can raise eyebrows, smile, close both eyes tightly, puff out both cheeksVIII Can HearIX, X (+) Gag ReflexXI Can shrug shoulderXII Tongue midline, good articulationMotor: Good muscle bulk and tone. Strength is 5/5 throughout.Cerebellar: No pronator drift. Gait with normal baseSensory: Pinprick, light touch, position and vibration sense intactReflexes: 2+

ADMITTING IMPRESSION:

• Chronic Inflammation, L foot; • Osteomyelitis; • T/C Madura Foot

DIFFERENTIAL DIAGNOSIS:

• Chronic Bacterial Osteomyelitis• Cutaneous Tuberculosis• Neoplasm

COURSE IN THE WARD11/28/2012 Blood Urea Nitrogen 5.0

Sodium 140Potassium 3.3Creatinine 97.4Reticulocyte count 0.55CBCWbcHemoglobinHematocritPlateletNeutrophilLymphocyteMonocyte

11.697.623.43147816.25.2

Left Foot AP-OThere is sclerosis of the visualized metatarsals and 1st proximal phalanx with small areas of lucencies. This may suggest osteomyelitis. There is soft tissue swelling and multiple soft tissue nodularities.

LEFT FOOT AP

SCLEROSIS WITH AREAS OF LUCENCIES

SOFT TISSUE NODULARITIES

SOFT TISSUE SWELLING

COURSE IN THE WARD• Oxacillin 1g TIV q4

• Shifted to: Ampicillin 1g IV q8 + Gentamycin 7mg/kg/day

• Levofloxacin 750mg tab OD was added

Debridement and curettage was done.

TREATMENT

• GSCS of wound: no growth after 5 days of incubation

• Tissue biopsy: revealed fibroconnective tissue containing numerous grayish-blue granules surrounded by abscess. Histopathologic diagnosis consistent with mycetoma.

TREATMENT:• Trimethroprim-Sulfamethoxazole 800/160mg/tab BID x 3

months • Streptomycin (14mg/kg/day) 700mg IM OD x 1 month,

then 3x/week for the next 2 months

After 1 week of treatment…

ON FOLLOW UP…

• At the OPD…• (+) hypersensitivity to

trimethoprim-sulfamethoxazole dose was adjusted and eventually discontinued.

Hypersensitivity to trimetophrim-sulfamethoxazole

Hypersensitivity to trimetophrim-sulfamethoxazole

On follow up…

• The patient has been followed up for the next four weeks without evidence of recurrence.

On follow up…

On follow up… 4 weeks after initiation of treatment.

FINAL DIAGNOSIS:

MADURA FOOT, LEFT

MYCETOMA• A chronic progressive granulomatous infection of the

skin and subcutaneous tissue • most often affecting the lower extremities typically a

single foot• TRIAD OF SYMPTOMS:

• localized swelling, • underlying sinus tracts, • production of grains or granules (comprised of

aggregations of the causative organism) within the sinus tracts

Mandell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

MADURA FOOT

FUNGI

• EUMYCETOMA

BACTERI

A

•ACTINOMYCETOMA

MYCETOMA

Mandell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

EPIDEMIOLOGY• Most commonly found in tropical and subtropical

climates, • One of the largest current group of cases is in Sudan• 5:1 male to female ratio• 20-40 year old age range• More common in agricultural workers and outdoor

laborers• M. mycetomatis: Most common cause• Drier regions: A. madurae, M. mycetomatis, S.

somaliensis• Wet regions: P. boydii, Nocardia, A. pelletieri

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

CLINICAL MANIFESTATIONS• 75%: lower extremities foot (70%)

single, small lesion, painless subcutaneous nodule

increases in size

becomes fixed to the underlying tissue

sinus tracts formation

open to surface drain purulent material with grains

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

• Overlying skin appears smooth and shiny

• Skin may be hyper or hypopigmented

• Swelling is firm and nontender

• Extensive local damage may lead to muscle wasting, bone destruction and limb deformities

• No signs or symptoms of systemic illness.

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

DIAGNOSIS:CLASSIC TRIAD

Painless soft tissue swelling

Draining sinus tracts

Extrusion of grains

DIAGNOSIS

• Deep biopsy with histopathology and culture is usually not necessary, although deep tissue biopsy avoids the bacterial contamination of surface cultures.

• Alternative strategy: aspiration of grains directly from an unopened sinus tract for microscopic observation and culture to diagnose the specific cause of mycetoma

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

MICROSCOPIC DIFFERENTIATION BETWEEN ACTINOMYCETOMA vs EUMYCETOMA

• Actinomycetes have granules of about 100 µm in diameter, with delicate, branched filaments measuring about 1 µm in diameter.

• fungal grains are observed as a mass of hyphae embedded in intercellular cement, and the filaments are wider than 1 µm.

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

DIAGNOSIS: ROLE OF RADIOLOGY• Important in: assessment of disease extent, bone

involvement, and long term follow up of disease regression and or progression.

• ULTRASONOGRAPHY:• EUMYCETOMA : produce single or multiple thick-

walled cavities, without acoustic enhancement, with grains represented as distinct hyperreflective echoes

• ACTINOMYCETOMA: grains produced fine echoes that were found at the bottom of the cavities

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

DIAGNOSIS:• MAGNETIC

RESONANCE IMAGING• “dot-in-circle” sign

• CT SCAN• Sensitive for detecting

early changes consistent with bone involvement

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

TREATMENT: ROLE OF SURGERY• In eumycetoma, if the patient's disease

has not responded to antifungal medical treatment wide local and debulking excisions and even amputation

• In actinomycetoma: amputation is infrequently indicated

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

TREATMENT: ACTINOMYCETOMA• streptomycin (14 mg/kg/day IM) is given for the first

month (and sometimes three times weekly thereafter for several months) in addition to a long course of TMP-SMX, usually one double-strength tablet (160 mg trimethoprim and 800 mg sulfamethoxazole) twice daily, or dapsone (1.5 mg/kg/day twice daily)

• Alternate regimens: • TMP-SMX + dapsone• amikacin +TMP-SMX.

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

TREATMENT: EUMYCETOMA

• Itraconazole (400 mg/day) or ketoconazole (200 to 400 mg/day) are considered first-line azole agents in the treatment of this disease

• Successful therapy with terbinafine, an allylamine antifungal, has also been reported

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

Mendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

THANK YOU!