Madura Foot

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CASE MANAGEMENT

CASE MANAGEMENTPresentor: Dr. Shayne CallejaModerator: Dr. Francia BalatanResource Speakers: Dr. Joey RanolaDr. Willbur BellecaMADURA FOOT

GENERAL OBJECTIVETo present a case of a rare chronic foot infection.

SPECIFIC OBJECTIVESTo discuss the clinical presentation of Madura foot that differentiates it from other foot infectionsTo show the characteristic radiological findings as well as macroscopic and microscopic presentation of Madura footTo present the diagnostic and treatment approach in patients with Madura footTo discuss the role of surgical intervention in the management of Madura foot

GENERAL DATACW.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 ILLNESS36 MONTHS PTA (+) insect bite at the dorsum of his left foot swollenConsultation 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 ILLNESS12 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 ILLNESS9 months PTA, (+) swelling of his left foot with intermittent discharge of pus, consulted an Infectious Disease specialist anti-kochs meds started jaundice anti-Kochs discontinued given Godex, anti-kochs resumed in separate tabletsLiver function tests: normal

HISTORY OF PRESENT ILLNESS4 months PTA, (+) painless subcutaneous nodules and sinus tracts with yellowish exudatessought second opinion with an orthopedic surgeonCT scan of the left foot: osteomyelitisAdvised I and D and possible amputation refused surgical managementreturned to the ID specialist: anti-kochs medications continued

HISTORY OF PRESENT ILLNESS1 month PTA(+) painless subcutaneous nodules and sinus tracts with yellowish exudatesCloxacillin sodium was added to his anti-kochs regimen.

HISTORY OF PRESENT ILLNESS1 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 paracetamolWound dressing with Terramycin ointment.

HISTORY OF PRESENT ILLNESSFew 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 EXAMINATIONPatient is conscious, coherent, not in cardiorespiratory distressBP: 90/60 PR: 60RR: 19T: 36.3Pale palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no nasoaural discharge, no palpable cervicolymphadenopathy, (+) inguinal lymphadenpathySymmetrical chest expansion, no retraction, no crackles, no wheezesAdynamic precordium, normal rate, regular rhythm, goodS1 and S2, apex beat at 5th ICS LMCL, no murmur

PHYSICAL EXAMINATIONAbdomen 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 intactVIICan raise eyebrows, smile, close both eyes tightly, puff out both cheeksVIIICan HearIX, X(+) Gag ReflexXICan shrug shoulderXIITongue 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 OsteomyelitisCutaneous TuberculosisNeoplasm

COURSE IN THE WARD11/28/2012Blood Urea Nitrogen5.0Sodium140Potassium3.3Creatinine97.4Reticulocyte count0.55CBCWbcHemoglobinHematocritPlateletNeutrophilLymphocyteMonocyte11.697.623.43147816.25.2

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 WARDOxacillin 1g TIV q4

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

Levofloxacin 750mg tab OD was added

Debridement and curettage was done.

TREATMENTGSCS 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 UPAt the OPD(+) hypersensitivity to trimethoprim-sulfamethoxazole dose was adjusted and eventually discontinued.

Hypersensitivity to trimetophrim-sulfamethoxazole

Hypersensitivity to trimetophrim-sulfamethoxazole

On follow upThe 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

MYCETOMAA chronic progressive granulomatous infection of the skin and subcutaneous tissue most often affecting the lower extremities typically a single footTRIAD OF SYMPTOMS: localized swelling, underlying sinus tracts, production of grains or granules (comprised of aggregations of the causative organism) within the sinus tractsMandell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

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

EPIDEMIOLOGYMost commonly found in tropical and subtropical climates, One of the largest current group of cases is in Sudan5:1 male to female ratio20-40 year old age rangeMore common in agricultural workers and outdoor laborersM. mycetomatis: Most common causeDrier regions: A. madurae, M. mycetomatis, S. somaliensisWet regions: P. boydii, Nocardia, A. pelletieriMendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

CLINICAL MANIFESTATIONS75%: 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 shinySkin may be hyper or hypopigmentedSwelling is firm and nontenderExtensive local damage may lead to muscle wasting, bone destruction and limb deformitiesNo 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

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

MICROSCOPIC DIFFERENTIATION BETWEEN ACTINOMYCETOMA vs EUMYCETOMAActinomycetes have granules of about 100 m in diameter, with delicate, branched filaments measuring about 1 m in diameter. fungal grains are observed as a mass of hyphae embedded in intercellular cement, and the filaments are wider than 1 m.

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

DIAGNOSIS: ROLE OF RADIOLOGYImportant 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 echoesACTINOMYCETOMA: grains produced fine echoes that were found at the bottom of the cavitiesMendell, Douglas, and Bennett's Principles and Practice of infectious Diseases, 7th ed.

DIAGNOSIS:MAGNETIC RESONANCE IMAGINGdot-in-circle signCT SCANSensitive for detecting early changes consistent with bone involvement

Mendell, Douglas,