A Chronic Foot Infection

1. CASE MANAGEMENT
Presentor: Dr. Shayne Calleja
Moderator: Dr. Francia Balatan
Resource Speakers:
Dr. Joey Ranola
Dr. Willbur Belleca
MADURA FOOT

2. GENERAL OBJECTIVE
• To present a case of a rare
chronic foot infection.

3. 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

4. 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

5. CHIEF COMPLAINT:
• Infected wound, left foot

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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.

12. HISTORY OF PRESENT ILLNESS
• Few hours PTA,
• (+) pain, swelling and eruption of several
subcutaneous nodules with sinus tracts
ADMITTED

13. PAST MEDICAL HISTORY:
• (-) Hypertension,
• (-) Diabetes Mellitus,
• (-) PTB,
• (-) Bronchial Asthma
• (-) History of travel to endemic places

14. PERSONAL/SOCIAL HISTORY:
• Patient is a veterinarian.
• A non-smoker, non-alcoholic beverage drinker.

15. FAMILY HISTORY:
• Unremarkable

16. ROS:
(-) Weight Loss (-) Anorexia
(-) Cough/colds (-) Dyspnea (-) Easy Fatigability
(-) chest pain (-) Orthopnea
(-) Changes in bowel habits (-) melena (-) hematochezia
(-) polyuria (-) polydypsia (-) polyphagia
(-) limitation of movement

17. PHYSICAL EXAMINATION
Patient is conscious, coherent, not in cardiorespiratory
distress
BP: 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, good
S1 and S2, apex beat at 5th ICS LMCL, no murmur

18. 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.

19. DORSUM OF LEFT FOOT

20. DORSUM OF LEFT FOOT

21. PLANTAR ASPECT OF LEFT FOOT

22. PHYSICAL EXAMINATION
Neuro Exam:
Patient is oriented to time, place and person.
I – Can smell coffee
II, III – Pupils equally reactive to light
III, IV, VI – Extraocular movements intact
V - Corneal Reflex intact
VII Can raise eyebrows, smile, close both eyes tightly, puff out
both cheeks
VIII Can Hear
IX, X (+) Gag Reflex
XI Can shrug shoulder
XII Tongue midline, good articulation
Motor: Good muscle bulk and tone. Strength is 5/5 throughout.
Cerebellar: No pronator drift. Gait with normal base
Sensory: Pinprick, light touch, position and vibration sense intact
Reflexes: 2+

23. ADMITTING IMPRESSION:
• Chronic Inflammation, L foot;
• Osteomyelitis;
• T/C Madura Foot

24. DIFFERENTIAL DIAGNOSIS:
• Chronic Bacterial Osteomyelitis
• Cutaneous Tuberculosis
• Neoplasm

25. COURSE IN THE WARD
11/28/2012 Blood Urea Nitrogen 5.0
Sodium 140
Potassium 3.3
Creatinine 97.4
Reticulocyte count 0.55
CBC
Wbc
Hemoglobin
Hematocrit
Platelet
Neutrophil
Lymphocyte
Monocyte
11.69
7.6
23.4
314
78
16.2
5.2

26. Left Foot AP-O
There 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.

27. LEFT FOOT AP
SCLEROSIS WITH
AREAS OF LUCENCIES
SOFT TISSUE
NODULARITIES
SOFT TISSUE
SWELLING

28. COURSE IN THE WARD
• Oxacillin 1g TIV q4
• Shifted to: Ampicillin 1g IV q8 + Gentamycin 7mg/kg/day
• Levofloxacin 750mg tab OD was added

29. Debridement and curettage was done.

30. 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.

31. 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

32. After 1 week of treatment…

33. ON FOLLOW UP…
• At the OPD…
• (+) hypersensitivity to
trimethoprim-
sulfamethoxazole
dose was adjusted
and eventually
discontinued.

34. Hypersensitivity to trimetophrim-
sulfamethoxazole

35. Hypersensitivity to trimetophrim-
sulfamethoxazole

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

37. On follow up…

38. On follow up… 4 weeks after initiation of
treatment.

39. FINAL DIAGNOSIS:
MADURA
FOOT,
LEFT

40. 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.

41. MADURA FOOT
FUNGI • EUMYCETOMA
BACTERIA • ACTINOMYCETOMA
MYCETOMA
Mandell, Douglas, and Bennett's Principles and Practice of infectious
Diseases, 7th ed.

42. 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.

43. 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.

44. • 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.

45. DIAGNOSIS:
CLASSIC
TRIAD
Painless soft
tissue swelling
Draining sinus
tracts
Extrusion of
grains

46. 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.

47. 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.

48. 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.

49. 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.

50. 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.

51. 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.

52. 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.

53. THANK YOU!
Mendell, Douglas, and Bennett's
Principles and Practice of