A Case Study on
A Case Study on
MycetomaIn Partial Fulfillment of the Course Requirement in
BacteriologySUBMITTED BY:Lapidez, Jann AlexaManrique,
JesselleMatuco, Julio NicolasMolos, Rachel Joyce C.Monarca, Riza
JuneMondragon, MoniqueNor, Jasmin B.Panceras, Wilfredo IIPastoril,
Miguel LorenzoVergara, Marielle Anna ElouiseGroup
5BacteriologyDavao Medical School Foundation HospitalSUBMITTED
TO:Prof. Ann Jun NicolasBacteriology CEP InstructorOctober 2014
Objectives of the Study
This study aims to: To gather significant information that will
help in the diagnosis of the patients condition To correlate
medical history and laboratory results with patients signs and
symptoms in order to make appropriate and accurate diagnosis To
compare the diagnosis to other diseases that may also fit the
patients condition To be able to defend the findings with the help
of laboratory results and other information regarding it To
recommend the best treatment for the patients condition To present
safety precautions to establish prevention form this kind of
infectionCHAPTER 1INTRODUCTIONAgriculture in the Philippines
employs 32% of the Filipino workforce (World Bank, 2013). This
includes horticulture, which deals in plant cultivation, landscape
restoration, garden design, construction, and maintenance. Despite
marked economic and household impact of this practice, the farmers
are faced with environmental andhealth challenges that need
intervention, proper diagnosis and treatment. The warm tropical
climate and its interaction with cultural practices, occupation and
immune responsiveness contribute to increased susceptibility to
fungal infections. Skin injuries, traumatic or not, cannot be
avoided in these situations. These injuries predisposes to
inoculation of contaminated wound.
Like in this case, a 55 year old male who enjoys horticulture
embedded a splinter into the palmar surface of his right hand near
the base of the thumb while handling the wooden poles. He was
unable to pull out the splinter and it remained embedded in a few
days. When the soreness disappeared, he removed the splinter using
a straight pin sterilized over the flame. The injured area healed
without an incident and the initial wound healing remained largely
forgotten until weeks later when a small subcutaneous swelling,
which was firm to touch but painless, developed on his right hand.
Eventually, a blister appeared at the base of the thumb, which soon
opened to discharge a serosanguinous exudate. Medical attention was
sought, and the presence of yellowish, firm granules ranging in
size of 1 to 2 mm was observed in the abscess drainage. The sample
was then sent to the microbiology section for routine, anaerobic
and fungus cultures.
With the above mentioned patient history, and accompanying
laboratory results through culture and routine examination, patient
diagnosis is presumptive of Mycetoma caused by Scedosporium
apiospermum (anamorphic form of Pseudallescheria boydii). This
fungus is saprophytic, frequently isolated from agricultural soil
and is acquired through traumatic inoculation, which in this
incident is through splinter. White to yellowish firm granules is
usually present in the fluid from the infected area that, in this
case, was observed during gross examination of the abscess
drainage. Microscopic examination revealed marked fungal morphology
of Scedosporium apiospermum with conidia that is unicellular and
ovoid with distinct brown wall and is not dimorphic.Though
Scedosporium apiospermum, by patient history and laboratory
findings, was easily assumed to be the causative agent, association
to further studies and other information must be made to finally
conclude the most accurate diagnosis and appropriate treatment for
this presented case.CHAPTER 2PATIENTS DATA WITH HISTORYThis chapter
presents the patients pertinent clinical data to further
investigate the cause of infection. Moreover, this includes the
medical history and the signs and symptoms being exhibited by the
patient. These data, in correlation to further studies and other
information, could be the basis leading to the patients proper
diagnosis.Personal Data Age: 55 years old Sex: male Enjoys
horticultureMedical History A splinter was embedded into the palmar
surface of the right hand near the base of the thumb. The splinter
remained embedded in a few days. The soreness disappeared and the
splinter was removed using a straight, sterilized pin. Weeks later,
a small subcutaneous swelling, firm and painless, developed on the
right hand. A blister appeared at the base of the thumb that
eventually opened to discharge a serosanguinous exudate.Laboratory
Results
Gross examination of abscess drainage: presence of 1-2 mm,
yellowish, firm granules KOH preparation
Central part of granules: 2-5 um in diameter hyaline hyphae
Peripheral part of granules: swollen hyphae with 10-20 um oval
cells SDA culture yield
Top: white, cottony colonies that later turned gray
Reverse: white colonies that later turned gray Microscopic
examination
Organism: do not exhibit dimorphism
Hyphae: septate hyaline hyphae, 2-4 um in diameter
Conidia: unicellular, ovoid, 9 x 5 um in diameterborne
terminally, singly, or in small groups on elongated, narrow, erect,
simple or branched conidiophoreslarger end toward the apex appeared
to be cut off at the base, with distinct brown wallCHAPTER 3
DEFINITION OF THE CASE A. Definition of the CaseHorticulture is
a branch of agriculture concerned with the cultivation of garden
plants. They are more focused on fruits, vegetables, flowers and
ornamentals used for landscaping. Two important horticultural
techniques are training (changing a plant's orientation in space)
and pruning (judicious removal of plant parts), which is used to
improve the appearance or usefulness of plants. Tools such as a
pruning knife, hand clippers, looping shears, and pruning saws are
needed for pruning. Optional equipment includes hedge shears, pole
pruners, and wood rasps. Pole pruners are used to cut overhead
branches that might otherwise be difficult to reach. They have a
cutter with a hooked blade above and a cutting blade below. The
poles can either be in sections that fit together or telescoping.
The poles may also wooden, aluminum, fiberglass or plastic. Using
of wooden pruner poles may be of high risk to the user when no
proper protective equipment is worn. Such examples of risks are
accidental embedding of splinter from the wooden pole into the
users hands, penetrating the integument.Such accidents, if remained
untreated, might worsen the initial condition. Symptoms such as
soreness, redness, or in worse cases, swelling, may develop.
Subcutaneous swelling might be painless or painful, firm or soft.
Blisters may start to appear if still left untreated. Manifestation
of blisters will produce discharges. Discharges may be in the form
of a serous drainage: a clear, thin, watery plasma normally seen
during the inflammatory stage of wound healing, sanguinous exudate:
seen in deep partial-thickness and full-thickness wounds, or a
serosanguinous exudate: a thin, watery, and pale red to pink color
and the pink tinge, which comes from red blood cells, indicating
damage to the capillaries. In cases when serosanguinous exudate
discharges are seen, medical help should be sought as damage to the
capillaries usually indicate local infection, which may later
develop into a systemic infection. Upon encountering a patient with
a similar clinical picture, the physician must further examine the
blister. In the case of this study, the physician expressed more
fluid from the tumor-like lesion, which are due to enlargement and
formation of nodules, noticing the presence of yellowish, firm
granules ranging in size 1-to 2 mm. Abscess drainage, a collection
of pus in the skin which may contain bacteria or fungal elements,
was collected using a needle and a syringe after careful cleansing
of the overlying skin, was submitted to the microbiology section
for routine, anaerobic, and fungus cultures. This drainage. Once
the fungal element is suspected as the cause of infection, a KOH
examination and culture studies of the specimen is performed.
Identification of morphologic characteristics of the granules and
colonies, macroscopically and microscopically will determine the
disease inflicting the patient, which in this case is Mycetoma as
suggested by the presence of yellow granules with sizes ranging 1-2
mm, with hyphae swollen at the periphery and supported by
laboratory studies which yielded white, cottony, and spreading
colonies which later turned gray in Sabourauds Dextrose Agar, with
microscopic examination yielding septate hyaline hyphae with
unicellular conidia borne terminally, singly, or in small groups on
elongated, narrow, erect simple or branched conidiophores, which
bears an ovoid shape and a distinct brown wall.Mycetoma is a
chronic subcutaneous infection induced by traumatic inoculation
with any of several saprophytic species of fungi or actinomycetous
bacteria that are normally found in soil. The clinical features
defining mycetoma are local swelling of the infected tissue and
interconnecting, often draining, sinsuses or fistulae that contain
granules, which are microcolonies of the agent embedded in tissue
material, that may either be black, white, yellow or red. The
disease also causes tumors as a consequence of a progressive and
relatively painless swelling. Mycetoma can be caused by more than
20 moulds, both hyaline and pigmented. Four fungi namely, Madurella
mycetomatis, Scedosporium apiospermium, Leptosphaeria senegalensis,
and Madurella grisea, account for approximately 95% of mycetoma
cases. Granules of mycetoma may range up to 2 mm in size with
hyphae typically distorted and enlarged at the periphery of the
granule. Color of the granules may provide the information of the
causative agent of the mycetoma. For example, granules Acremonium,
Fusarium and Scedosporium apiospermium are white to yellow while
granules of Madurella, Phialophora, Curvularia, and Exophiala
jeanselmei are black.B. Anatomy The integument, which simply means
covering, is essential part of the body because it keeps water and
other precious molecules in the body. The integumentary system has
many functions. Most, but not all, are protective. It insulates and
cushions the deeper body organs and protects the entire body from
mechanical damage (bumps and cuts), chemical damage (such as from
acids and bases), thermal damage (heat and cold), ultraviolet
radiation (in sunlight), and microorganisms. The upper most layer
of the skin is made up of keratin and is cornified, or hardened, to
help prevent water loss from the body surfaces.The skins rich
capillary network and sweat glands play an important role in
regulating heat loss from the body surface. The skin also acts as a
mini-excretory system and also manufactures several proteins
important to immunity and synthesizes vitamin D. The cutaneous
sensory receptors, located in the skin, include touch, pressure,
temperature, and pain receptors.
The skin is composed of two kinds of tissue. The upper epidermis
is made up of stratified squamous epithelium that is capable of
keratinizing, or becoming hard and tough while the underlying
dermis is made up of mostly of dense connective tissue. The
epidermis and dermis are firmly connected. However, a burn and/or
friction may cause them to separate, allowing interstitial fluid to
accumulate in the cavity between the layers, which results in a
blister.
Below the dermis is the subcutaneous tissue, or hypodermis,
which is essentially made adipose tissue. Though it anchors the
skin to underlying organs, it is not considered part of
it.Epidermis
The epidermis is composed of up to five layers; stratum basale,
spinosum, granulosum, lucidum, and corneum. Like all the other
epithelial tissue, the epidermis is avascular. Most cells of the
epidermis are keratinocytes, which produce keratin, the fibrous
protein that makes the epidermis a tough protective layer. The
basal layer, stratum basale, lies closest to the dermis and is
connected to it along a wavy borderline that resembles a corrugated
cardboard. This basal layer contains epidermal cells that receive
most of the adequate nourishment via diffusion of nutrients from
the dermis. These cells constantly undergo cell division, producing
millions of new cells daily; hence its alternate name stratum
germinativum. The daughter cells are pushed upward to become part
of the epidermal layers closer to the skin surface and become part
of the more superficial layers, the stratum spinosum and the
stratum granulosum. They become flatter and increasingly full of
keratin. Finally they die, forming the clear stratum lucidum. The
outermost layer, the stratum corneum, accounts for about three
quarters of the epidermal thickness.
Dermis
The dermis is a strong, stretchy envelope that helps to hold the
body together. The dense (fibrous) connective tissue making up the
dermis consists of two major regions- the papillary and the
reticular areas. The papillary layer is the upper dermal region and
it is uneven and has peglike projection from its superior surface,
called dermal papillae, which intent the epidermis above. Many of
the dermal papillae contain capillary loops, which furnish
nutrients to the epidermis. On the palms of the hands and soles of
the feet, the papillae are arranged in definite patterns that form
looped and whorled ridges on the epidermal surface that increase
friction and enhance the gripping ability of the fingers and feet.
The reticular layer is the deepest skin layer and contains blood
vessels, sweat and oil glands, and deep pressure receptors called
Pacinian corpuscles. Phagocytes present here act to prevent
bacteria that have managed to get through the epidermis from
penetrating deeper into the body. C. Pathophysiology Mycetoma is
caused by the traumatic inoculation of the causative agent into the
hands and feet. After inoculation occurs, a poorly defined host
response precludes the development of free fungal filaments in the
infected tissue, specifically the subcutaneous tissue, leading to
the development of the characteristic grain. Neutrophil mediated
tissue reaction leads to partial grain disintegration, but most
granules are left undamaged resulting in swelling and inflammation.
Macrophages and multinucleated giant clear dead neutrophils and
grain fragments, resulting in the formation of abscesses and
granulomatas, with drainage containing granules.
In the case given to the group, soreness of the hand was caused
by the splinter embedded in the skin, which was later removed few
day after the pain had subsided. Subcutaneous swelling was then
observed with a blister eventually forming on the base of the
patients thumb, which soon opened to discharge a serisanguinous
exudate. Medical examination of the exudate revealed the presence
of yellowish, firm granules ranging in 1-2 mm in size. Also,
culture studies revealed growth of white, cottony colonies, which
later turned gray with the reverse as white which also turned gray,
on Sabourauds Dextrose Agar. Mycetoma is the indicative disease of
the patient as fungi was introduced to the tissue through the
embedment of the splinter. Color of the granules indicate that the
causative agent of the mycetoma is Scedosporium apiospermum.
Swelling of the tissue is due to presence of macrophages and
multinucleated cells in the tissue. The presence of both cells is
elicited by the presence of dead neutrophils that have failed to
eliminate free fungal elements carried by the splinter and grain
fragments which are left-overs of neutrophils engulfing free fungal
filaments. Increased size of the tissue caused by the swelling
causes damage to capillaries on infected site, which leads to
leakage of red blood cells, explaining the serosanguinous
characteristic of the exudate.CHAPTER 4LABORATORY RESULTS AND
TREATMENT
A. Laboratory ResultsTestResultsInterpretation
Gross Examination of abscess drainagepresence of 1-2 mm,
yellowish, firm granules
KOH preparationCentral part of granules: 2-5 um in diameter
hyaline hyphaePeripheral part of granules: swollen hyphae with
10-20 um oval cellsPresence of fungal elements in abscess
drainage
Subculture on SDATop: white, cottony colonies that later turned
grayReverse: white colonies that later turned gray
Presence of fungi in abscess drainage
10 % Sheep Blood AgarNo growthNo presence of bacteria in abscess
drainage
Microscopic examinationOrganism: do not exhibit
dimorphismHyphae: septate hyaline hyphae, 2-4 um in
diameterConidia: unicellular, ovoid, 9 x 5 um in diameter borne
terminally, singly, or in small groups on elongated, narrow, erect,
simple or branched conidiophores larger end toward the apex
appeared to be cut off at the base, with distinct brown
wallPresumptive identification of Scedosporium apiospermum
B. Treatment/Medication & Management (Medication and its
action)The most recommended medical action for Scedosporium
apiospermum mycetoma due to traumatic inoculation of fungus into
the dermal or subcutaneous tissue is surgical debridement with
accompanying antifungal therapy on the site of infection. However,
less invasive treatment can also be done using the antifungal
treatment alone. Voriconazole, an azole derivative, acts on the
ergosterol biosynthesis by inhibiting the enzyme, 14-demethylase,
that leads to the depletion of ergosterol and resulting in the
formation of a plasma membrane with altered structure and
function.CHAPTER 5
SUMMARY, CONCLUSION & RECOMMENDATION
A. Summary
The patient, a 55 year old male, embedded a splinter into the
palmar surface of his right hand near the base of the thumb while
handling wooden poles. The splinter was pulled out a few days after
soreness had subsided. Few weeks after the splinter was removed,
subcutaneous swelling, which was painless and firm to touch, was
observed on his right hand. Manifestation of a blister near the
base of his thumb was observed later on. The blister discharged
serosanguinous exudate which made the patient sought for medical
attention.
Yellow, firm granules were observed from the fluid ranging 1 to
2 mm in size. Abscess drainage was aspirated and was sent to
laboratory for routine anaerobic and fungal cultures.
KOH examination revealed the presence of hyaline hyphae, 2-5 um
in diameter, in the central part of the granule, with the periphery
of the granule swollen producing oval cells 10-20 um in size.
Culture studies of the exudate yielded in the growth of white,
cottony and spreading colonies that later turned gray with reverse
having a white color which also turned gray later on. Microscopic
examination of the colonies revealed that the fungi possessed a
septate hyaline hyphae 2-4 um in diameter borne terminally, singly
or in small groups on elongated narrow, erect, simple or branched
conidiophores. The conidia was observed to ovoid in shape, with the
larger end near the apex appearing to be cut off at the base,
possessing a distinct brown wall and not exhibiting dimorphism.
Results of the study indicate that the patient is afflicted with
Mycetoma which is caused by traumatic inoculation of the fungi to
the hands or feet, resulting in swelling and granulomata formation
of the infected site. Color of the granules indicate that the
causative agent of the disease is Scedosporium apiospermumB.
Conclusion
The 55 year old male had subcutaneous fungal infection which he
acquired from a splinter that was embedded into his right hand.
Patients manifestations such as the presence of a tumor-like
lesion, serosanguinous exudate and yellowish, firm granules are
clinical characteristics of mycetoma. Laboratory results highly
suggest that the organism is Scedosporium apiospermum. C.
Recommendation
According to the data and information gathered by the
proponents, it is therefore recommended: Treatment of disease using
antifungals such as triazole and voriconazole.
Wear of protective equipments such as gardening gloves to
protect the patients hands against cuts, soil, insect bites and
skin irritants. Leather gloves offer protection against puncture
injuries from thorns.
Use appropriate tools for digging (for example, a shovel or hand
shovel). Buried objects such as tree roots, glass and metal objects
can cause injuries to the hand, wrist or arm while digging.
Use of protective shoes, lightweight comfortable clothes (e.g.
long-sleeves) that cover exposed skin.
Consultation with a doctor about cuts and puncture wounds that
happened during horticulture or gardening as injuries are at risk
for tetany.CHAPTER VI
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