Case Report A case report of Maduramycosis.

Maduramycosis is a chronic progressive granulomatous condition which causing infection of the skin which ultimately leads to involvement of the bone. Causative organisms maybe either bacteria (actinomycetoma) or fungi (eumycetoma). The causative organism is inoculated usually after minor foot trauma and so it is more often seen in barefoot-walking populations exposed to contaminated soil during minor injuries. It is common in adults aged between 20 to 50 years. The classical clinical features are tumefaction, fistulization of the abscess, and extrusion of coloured grains. In the active phase of the disease the colour of these extruded grains from the fistulas aid in diagnosis. Radiography, ultrasonography, MRI, cytology, histology, immunodiagnosis, and culture are the investigations which are used for diagnosis.


Introduction
Mycetoma is a chronic granulomatous disease most commonly affecting body parts that are in direct contact with soil during daily activities, that is feet, legs, hands, and, occasionally, the head or back. 1 It is most commonly seen in tropical and subtropical regions & rarely in temperate regions.It is difficult to diagnose mycetoma based on the similar clinical features of both actinomycetoma & eumycetoma, so it is usually misdiagnosed in the early stages to be a

Discussion
Mycetoma was characterized first in the mid-1800s in Madura district of southern India and was initially known as Madura foot 4 .Mycetoma or Madura foot is a chronic granulomatous inflammatory disease affecting subcutaneous tissues and skin.The causative organisms fall under two groups namely bacteria Actinomyces (Actinomyetoma) or true fungi (Eumycetoma). 5redominance of rainfall favours infection by actinomycetoma and eumycetoma infection is more commonly noted in regions receiving scarce rainfall. 6xtremities are usually affected (most commonly the foot, leg or hand) owing to penetrating injury by which the organisms in the soil are implanted.The course of the disease is an indolent one in which infection may persist latent for a long time and the disease evolves slowly and it is usually painless with delayed presentation. 7This infection results in a granulomatous inflammatory response in the deep dermis and the subcutaneous tissues with formation small, subcutaneous swellings that enlarge, soften with pus and breach the skin surface, with invasion of deeper tissues. 8ter many years as the disease progresses, bone invasion results in replacement of osseous tissue by grains and multiple foci of osteolysis.Other features seen in this infection are abscess formation, draining sinus tracts, osteomyelitis, and fistula formation, resulting in severe deformity and disability if early treatment is not provided. 9The colour of the grains in the discharge will indicate the type of infection.Black or pale grains are usually seen in eumycetoma and white, yellow or red grains are seen in actinomycetoma.
Early in the course of disease, no abnormality is seen on radiographs because the bone  may not be involved.Common radiographic findings are bone sclerosis, periosteal reaction, bone cavities, cortical scalloping, osteoporosis and soft-tissue thickening.Bone lesions of eumycetoma usually form few cavities, which are one centimetre or greater in diameter usually, whereas those of actinomycetes usually have more number of cavities but are smaller in size, showing moth-eaten appearance. 10CT scan is better in delineating the bone changes than radiographs.
MRI findings of mycetoma are small foci showing hypointense signal on both T1W and T2W which is due to susceptibility artefacts from the formation of microabscesses consisting of aggregates of the organism (known as "grains") and surrounded by abundant granulation tissue.This can be visualised as "dot-in-circle" sign, initially described by Sarris et al in 2003, seen as tiny hypointense foci inside the hyperintense spherical lesions, on T2W, STIR, and T1W fat-saturated gadolinium-enhanced images.Correlating the MRI and histological findings, they suggested that the high-signal areas seen on MRI represent inflammatory granulomata, the fibrous matrix surrounding these lesions correspond to low signal intensity, and within the granulomata there fungal balls or grains which appear as central hypointense foci."Dot in circle" appearance was suggested to be a specific sign for mycetoma. 11trasound shows multiple round hypoechoic lesions with central hyperechoic foci showing "dot-in-circle" appearance which is similar to its appearance in MRI. 12 Histologically, a typical mycetoma consists of a large granulomatous area with a purulent center surrounded by a thick fibrous capsule.Biopsy or staining and microbiological culture of discharge from the lesion helps in definitive diagnosis, but these are time-consuming procedures and hence diagnosis may be difficult to achieve. 13

Conclusion
Mycetoma is a chronic granulomatous infection of the feet.MRI demonstrates tiny hypointense foci inside the hyperintense spherical lesions seen as "Dot in circle" appearance which is diagnostic for mycetoma.
Figure: 2 (A,B & C).Contrast enhanced MRI of left foot & ankle was done in 1.5 Tesla SIEMENS MAGNETOM MRI scanner.MRI showed multiple well defined variable sized confluent T1 hypointense, T2/STIR hyperintense lesions with central hypointense focus giving 'dot in circle' appearance.These lesions are seen as rounded hyperintensity (representing granulation tissue), surrounding low signal intensity rim (representing fibrous septa) with a hypointense dot (representing susceptibility loss due to fungi) in the centre Figure:3 (A &B).J Clin Biomed Sci 2021; 11(4):171-173 Anil Kumar et al.A case report of Maduramycosis.

Figure 1 (
Figure 1(A&B): Radiograph of left ankle & foot shows soft tissue swelling around the ankle joint & foot.The tarsal bones including the calcaneum, talus, cuboid, navicular, medical cuneiform show multiple variable sized lytic lesions with cortical irregularity.

Figure 2 (
Figure 2(A, B & C): CT scan of the left ankle & foot shows multiple variable sized lytic lesions in calcaneum, talus, cuboid, navicular, medical cuneiform, distal end of tibia & fibula with cortical irregularity & loss of normal architecture with associated soft tissue swelling around the left ankle joint & foot.