Myelopathy secondary to thoracic actinomycetoma
Main Article Content
Keywords
Mycetoma, Nocardia, Fistula
Abstract
Background: Mycetoma is a chronic subcutaneous infection caused by fungi (eumycetoma) or filamentous bacteria (actinomycetoma), acquired through traumatic inoculation. It affects the skin, subcutaneous tissue, and in advanced cases, deeper structures such as bones or the spinal cord. Its presentation can lead to severe complications, including paraplegia.
Clinical case: 74-year-old male farmer hospitalized due to sudden-onset paraplegia, with inability to walk and urinary and fecal incontinence. A dermatology consult was requested for a dermatosis affecting the trunk, located on the posterior aspect of the left hemithorax, which was localized and asymmetrical. The lesion consisted of multiple fistulas discharging purulent secretion and numerous erythematous-violaceous atrophic scars that coalesced to form a plaque measuring 30 x 30 cm. Neurologically, a complete spinal cord syndrome was diagnosed. Microbiological studies revealed the presence of grains measuring between 50 and 100 μm composed of filamentous bacteria, positive for periodic acid–Schiff (PAS) stain and acid-fast with Ziehl-Neelsen staining, consistent with Nocardia spp. Magnetic resonance imaging showed involvement of vertebrae T6, T7, and T8.
Conclusions: Actinomycetoma is endemic in Mexico. The classic triad includes a subcutaneous mass, fistulas, and grains. Its progression can cause vertebral destruction and myelopathy. Magnetic resonance imaging is the diagnostic study of choice due to its high soft tissue resolution. Therapeutic management combines antibiotics with activity against actinomycetes.
References
1. Arenas R. Capitulo 99: Micetoma. En: Arenas R: Dermatología. Atlas, diagnóstico y tratamiento. 8ª ed. México: McGraw-Hill Interamericana; 2024:492-500.
2. Husain U, Verma P, Suvirya S, et al. An overview of mycetoma and its diagnostic dilemma: Time to move on to advanced techniques. Indian J Dermatol Venereol Leprol. 2023;89(1):12-7. doi: 10.25259/ijdvl_615_2021
3. Hao X, Cognetti M, Burch-Smith R, et al. Mycetoma: Development of Diagnosis and Treatment. J Fungi. 2022;8(7):743. doi: 10.3390/jof8070743
4. Casulli A. New global targets for NTDs in the WHO roadmap 2021–2030. PLoS Negl Trop Dis. 2021;15(5):e0009373. doi: 10.1371/journal.pntd.0009373
5. López-Martínez R, Méndez-Tovar LJ, Bonifaz A, et al. Actualización de la epidemiología del micetoma en México. Revisión de 3,933 casos. Gac Med Mex. 2013;149(5):586-92.
6. Enbiale W, Bekele A, Manaye N, et al. Subcutaneous mycoses: Endemic but neglected among the Neglected Tropical Diseases in Ethiopia. PLoS Negl Trop Dis. 2023;17(9):e0011363. doi: 10.1371/journal.pntd.0011363
7. Emery D, Denning DW. The global distribution of actinomycetoma and eumycetoma. PLoS Negl Trop Dis. 2020;14(9):e0008397. doi: 10.1371/journal.pntd.0008397
8. López NE, Salas MA, Ortiz CE, et al. Epidemiología del micetoma en el Centro Dermatológico de Yucatán (2001-2021). Dermatología CMQ. 2023;21(2):104-10.
9. Bonifaz A, Tirado-Sánchez A, Vázquez-González D, et al. Actinomycetoma by Actinomadura madurae. Clinical and therapeutic characteristics of 18 cases with two treatment modalities. J Dermatolog Treat. 2022;33(2):954-8. doi: 10.1080/09546634.2020.1793887
10. Agarwal P, Jagati A, Rathod SP, et al. Clinical features of mycetoma and the appropriate treatment options. Res Rep Trop Med. 2021;173-9. doi: 10.2147/rrtm.s282266
11. Ali EA, Ahmed KAHM, Alhusseini RT, et al. Neurological manifestations of mycetoma: a cross-sectional community-based study. Ann Med Surg. 2023;85(5):1590-3. doi: 10.1097/ms9.0000000000000122
12. Tarafdar S, Kanimozhi P, Sabarish S, et al. Magnetic resonance imaging in the diagnosis of mycetoma with equivocal clinical and laboratory features. Indian J Dermatol. 2022;67(4):459-63. doi: 10.4103/ijd.ijd_124_21
13. Siddig EE, Van de Sande WWJ, Fahal AH. Actinomycetoma laboratory-based diagnosis: a mini-review. Trans R Soc Trop Med Hyg. 2021;115(4):355-63. doi: 10.1093/trstmh/traa176
14. Welsh O, Salinas-Carmona MC, La Garza JA, et al. Current treatment of mycetoma. Curr Treat Options Infect Dis. 2018;10(3):389-96. doi: 10.1007/s40506-018-0171-y
15. Fahal AH, Ahmed ES, Bakhiet SM, et al. Two dose levels of once-weekly fosravuconazole versus daily itraconazole in combination with surgery in patients with eumycetoma in Sudan: a randomised, double-blind, phase 2, proof-of-concept superiority trial. Lancet Infect Dis. 2024;24(11):1254-65. doi: 10.1016/S1473-3099(24)00404-3
16. Luan T, Guido MR, Chammas M, et al. A Case Report of a Mysterious Mycetoma. Cureus. 2024;16(7). doi: 10.7759/cureus.64608
17. Alhaj AA, Ahmed ES, Hassan A, et al. Epidemiological observations and management challenges in extrapedal mycetoma: A three-decade review of 420 cases. PLoS Negl Trop Dis. 2024;18(5):e0011841. doi: 10.1371/journal.pntd.0011841
18. Chandler DJ, Bonifaz A, Van de Sande WW. An update on the development of novel antifungal agents for eumycetoma. Front Pharmacol. 2023;14:1165273. doi: 10.3389/fphar.2023.1165273
19. Chandler DJ, Davey G, Hay RJ, et al. Development of the Mycetoma Activity and Severity clinical Scale (MASS): an international Delphi study. Lancet Infect Dis. 2025;25(6):e345-52. doi: 10.1016/s1473-3099(24)00808-9
20. Van de Sande WW, Fahal AH. An updated list of eumycetoma causative agents and their differences in grain formation and treatment response. Clin Microbiol Rev. 2024;37(2):e00034-23. doi: 10.1128/cmr.00034-23
21. Estrada-Chávez GE, Estrada R, Fernandez R, et al. Cervical and middle dorsal actinomycetomas from Guerrero State, Mexico. Int J Dermatol. 2017;56(11):1146-9. doi: 10.1111/ijd.13775
22. Eaton KJ, Gulbrandsen MT, Obeid RA, et al. Twenty-year cervicothoracic Nocardia mycetoma with advanced thoracic cavity infiltration. JAAD Case Rep. 2019;5(8):697-700. doi: 10.1016/j.jdcr.2019.06.003
23. Martínez-Silva JA, Monreal-Molina R, Soto-Gaxiola AH, et al. Mielopatía cervicotorácica secundaria a micetoma. Orthotips. 2022;18(3): 258-62. doi: 10.35366/107277
Article Sidebar
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Authors retain their copyright and grant the Revista Médica del IMSS the right of first publication. Articles are distributed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which allows sharing as long as the author and the original source are properly credited.