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      El micetoma. revisión. Translated title: The mycetoma. review


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          Los autores presentan una revisión sobre el micetoma, tanto del actino como del eumicetoma. Presentan una puesta al día de esta infección, producida tanto por bacterias como por hongos. Revisan aspectos históricos del micetoma, incluyendo aspectos del mismo en algunos países de Latinoamérica. Actualizan aspectos relacionados con la epidemiología, el diagnóstico clínico, microbiológico, serológico y radiológico, haciendo comentarios a algunas nuevas técnicas de estudio del micetoma, tales como el ultrasonido y la toma de muestras de las lesiones por aspiración por aguja fina. Se discuten aspectos relacionados con el tratamiento del micetoma y, así mismo, se plantean algunas sugerencias que podrían contribuir a prevenir el impacto social de esta enfermedad, la cual representa, más que un problema importante de salud, un problema de tipo social.

          Translated abstract

          The authors present an overview on mycetomas, both actinomycetomas and eumycetomas. They provide an up to date summary of these infections produced by bacteria as well as fungi. They review the history of mycetomas and include specific information from some Latin American countries. They update aspects related to the epidemiology, the clinical diagnosis, microbiology, serology and radiology. They summarize some new mycetoma developments such as the use of ultrasound. They show sample collection techniques using fine needle aspiration for cytology of mycetomas. Moreover, they discuss the different treatments of mycetomas and provide suggestions to reduce the social impact of these diseases. Apparently, in addition of being an important health problem, mycetomas have also become a major social issue.

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          Nocardia species: host-parasite relationships.

          The nocardiae are bacteria belonging to the aerobic actinomycetes. They are an important part of the normal soil microflora worldwide. The type species, Nocardia asteroides, and N. brasiliensis, N. farcinica, N. otitidiscaviarum, N. nova, and N. transvalensis cause a variety of diseases in both normal and immunocompromised humans and animals. The mechanisms of pathogenesis are complex, not fully understood, and include the capacity to evade or neutralize the myriad microbicidal activities of the host. The relative virulence of N. asteroides correlates with the ability to inhibit phagosome-lysosome fusion in phagocytes; to neutralize phagosomal acidification; to detoxify the microbicidal products of oxidative metabolism; to modify phagocyte function; to grow within phagocytic cells; and to attach to, penetrate, and grow within host cells. Both activated macrophages and immunologically specific T lymphocytes constitute the major mechanisms for host resistance to nocardial infection, whereas B lymphocytes and humoral immunity do not appear to be as important in protecting the host. Thus, the nocardiae are facultative intracellular pathogens that can persist within the host, probably in a cryptic form (L-form), for life. Silent invasion of brain cells by some Nocardia strains can induce neurodegeneration in experimental animals; however, the role of nocardiae in neurodegenerative diseases in humans needs to be investigated.
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            A 46-year-old male, a grocer by occupation was referred from the orthopedics department for swelling of his right leg with discharge from overlying skin since 18 months. He was a known case of chronic osteomyelitis since 7 years. Cutaneous examination revealed diffuse swelling of right thigh and leg along with effusion of right knee joint. Also, there were multiple sinuses on right thigh and on upper one-third of right leg. Two sinuses were found discharging serosanguinous fluid along with black granules [Figure 1]. Multiple healed atrophic scars were noticed on right thigh. KOH preparation of the crushed granules showed septate branching phaeoid hyphae [Figure 2]. Culture on Sabouraud's dextrose agar was negative for maduramycosis. Radiograph of the right leg showed circumscribed osteolytic lesion in the metaphyseal region of right tibia [Figure 3]. Magnetic resonance imaging (MRI) of right leg showed well-defined, ovoid, mixed intensity lesion in the metaphyseal region of right upper one-third of tibia. The 'dot-in-circle' sign was visualized [Figure 4]. Lesional biopsy was noncontributory. Characteristic clinical morphology, microscopy of the granules, radiography, and MRI assisted in establishing the diagnosis of mycetoma. Figure 1 Multiple sinuses on right thigh and upper one-third of right leg. Two sinuses show discharging serosanguinous fluid along with black granules Figure 2 KOH mount of the crushed granules showing septate branching phaeoid hyphae Figure 3 Radiograph of right leg showing circumscribed osteolytic lesion in the metaphysical region of right tibia Figure 4 MRI of right leg showing well-defined ovoid mixed intensity lesion in the metaphyseal region of right upper one-third tibia with the 'dot-in-circle' sign (arrow) Mycetoma is a chronic granulomatous infection of the skin and subcutaneous tissues characterized by induration, abscess formation with draining sinuses. It is caused by both fungi (eumycetoma) and filamentous bacteria (actinomycetoma). It derives its name from Madurai, the place where it was first reported. The clinical features are the same irrespective of the causative agent.[1] Madurella mycetomatosis is one of the commonest causes of eumycetoma[2] and it is common among males who perform more outdoor activity. Usually follows injury such as a thorn prick or an injury resulting in ulceration. Similarly, mycetoma followed vehicular injury in our case. The foot is a common site of involvement followed by and extremities and perineum.[3] Involvement of the upper part of the leg in our case is in concert with the common sites of involvement. Confirmation of the diagnosis is by demonstration of the fungus and speciation by culture on Sabouraud's dextrose agar.[4] However, only fungal elements could be demonstrated in our case but failed to culture the fungus on Sabouraud's dextrose agar. The surface of the colony is heaped up, and radially folded with a glabrous to wooly texture. Its color varies from white to yellow-brown to dark gray or olive brown, whereas the reverse shows brown pigment. The causative fungus could not be established in our case as it could not be cultured. Nonetheless, black granules were found in the discharge overlying the sinuses, which is a characteristic clinical feature of eumycetoma. Bone involvement is a major complication in maduramycosis resulting in osteolytic lesions seen on radiography.[5] The upper end of tibia showed osteolytic lesions in our case. The recently described dot-in-circle sign on magnetic resonance imaging (MRI) is highly specific of maduramycosis.[6] Treatment of eumycetoma consists of antifungal drugs combined with surgery. Antifungal drugs such as itraconazole, posaconazole, ketoconazole, and terbinafine long are required to be administered for a long duration. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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              [Epidemiology of mycetoma in Mexico: study of 2105 cases].

              A survey was carried out in Mexico to determine the incidence and epidemiological characteristics of mycetoma. Data was collected from a total of 2105 cases of mycetoma throughout a 30 year period (1956-1985), with an average incidence of 70 cases per year. Results showed a sex distribution of 76.1% male and 23.9% females. Age distribution indicated a 35% between 16 to 30 and 23% between 31 to 40 year old population. Most cases occurred in land-workers (60.2%) and in housewives with rural residence (21.3%). Lesions occurred most frequently in lower limbs (64.1%), trunk (17.4%) and upper limbs (13.6%). The geographic distribution within Mexico revealed that the States with the highest incidence were: Jalisco, Nuevo León, San Luis Potosi, Morelos and Guerrero The predominant etiologic agents found 97.8% corresponded to actinomycetes, from which Nocardia brasiliensis (86.6%) and Actinomadura madurae (10.2%) showed the higher frequency. Eumycetoma (2.2%) was due to Madurella grisea and M. mycetomatis in most cases.

                Author and article information

                Revista de la Sociedad Venezolana de Microbiología
                Rev. Soc. Ven. Microbiol.
                Organo Oficial de la Sociedad Venezolana de Microbiología. (Caracas, DF, Venezuela )
                January 2003
                : 23
                : 1
                : 70-79
                [02] Xochimilco México DF orgnameUniversidad Autonoma Metropolitana orgdiv1Departamento de Sistemas Biologicos hsandov@ 123456cueyatl.uam.mx
                [01] Mérida orgnameUniversidad de Los Andes orgdiv1Facultad de Medicina orgdiv2Departamento de Fisiologia Venezuela jacielo@ 123456cantv.net
                S1315-25562003000100016 S1315-2556(03)02300116


                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 84, Pages: 10

                SciELO Venezuela

                Investigaciones Originales y Otras Modalidades de Publicación

                Micetoma, Nocardia, actinomicetoma, actinomicetos


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