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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 16  |  Issue : 2  |  Page : 94-95

Mycetoma caused by Exophiala jeanselmei


Department of Microbiology, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Web Publication14-Nov-2014

Correspondence Address:
Sathyabhama
Department of Microbiology, Government Medical College, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1282.144734

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  Abstract 

Exophiala jeanselmei is clinically redefined as a rare agent of subcutaneous lesions of traumatic origin eventually causing mycetoma. A case of eumycetoma of foot in a 42-year-old male was clinically diagnosed as dermoid cyst and was microbiologically confirmed as eumycetoma. This case is reported for its uncommon clinical presentation and etiological agent, Exophiala jeanselmei. The patient recovered completely after treatment with Ketoconazole.

Keywords: Eumycetoma, Exophiala jeanselmei, Ketoconazole


How to cite this article:
Sathyabhama, Bhageerathi S, Raj S. Mycetoma caused by Exophiala jeanselmei. J Acad Clin Microbiol 2014;16:94-5

How to cite this URL:
Sathyabhama, Bhageerathi S, Raj S. Mycetoma caused by Exophiala jeanselmei. J Acad Clin Microbiol [serial online] 2014 [cited 2020 Apr 5];16:94-5. Available from: http://www.jacmjournal.org/text.asp?2014/16/2/94/144734


  Introduction Top


Localized, slowly progressive, subcutaneous infections caused by fungi or actinomycetes are known as eumycetoma or actinomycetoma, respectively. The organisms are traumatically implanted into the deep dermis or subcutaneous tissue from the natural environment and cause a subcutaneous infection characterized by large aggregates of fungal filaments. It does not often spread beyond the locality of the initial site of infection and is seldom fatal. [1] Gill described the disease for the first time in India in a dispensary in Madura district, hence the derivation of Madura foot. [2] In India, about 65% of the cases are of actinomycetoma and the rest are of eumycetoma. [3] Exophiala jeanselmei has been reported as infrequently responsible for eumycetoma. [4]


  Case report Top


A 42-year-old male patient, resident of Thiruvananthapuram presented with swelling over the right foot of two years duration at the Outpatient Department of Surgery at General Hospital, Thiruvananthapuram, Kerala in September 2013. He was a diabetic and hypertensive working in animal husbandry. There was a history of injury of the same foot with a wooden splinter two and half years earlier. Examination revealed a painless indurated swelling on the right foot measuring 5 1.5 cm at the lateral aspect of the first metatarsal bone. There was no significant regional lymphadenopathy. Systemic examination was within normal limits.

Investigations: FNAC was done, which was suggestive of suppurative lesion of fungal etiology. The lesion was excised and the whitish discharge was sent to our lab for fungal culture.

Microscopic examination of 10%KOH mount revealed fungal hyphae. The specimen was inoculated on Sabouraud's dextrose agar and kept at 22˚C and 37˚C. After 10 days, black-colored colonies with velvety texture were observed. Lactophenol cotton blue (LPCB) mount showed cells resembling yeast cells except for the light brown pigment [Figure 1]. On further incubation the colonies turned gray with a jet black reverse [Figure 2]. Slide culture was done which showed septate pigmented hyphae of 4-5 μm diameter with stick like conidiophores tapered at the tip and topped at the apices with clusters of elliptical conidia [Figure 3]. Nitrate was reduced to nitrite. The microscopic morphology and conidiogenesis seen were compatible with Exophiala jeanselmei.
Figure 1: Young cultures of E. jeanselmei showing yeastlike cells

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Figure 2: Grey coloured colonies of E. jeanselmei on SDA

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Figure 3: Slide culture of E. jeanselmei showing conidiophores and clusters of elliptical conidia

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Oral Ketoconazole was given for two months. No adverse effects were reported.


  Discussion Top


Eumycetoma is characterized by a prolonged incubation period, slow and unremarkable clinical course and multiple causative agents. [5] The genus Exophiala is widely distributed in the environment and may cause infections both in immunocompromised and immunocompetent patients. [6] In several instances, it remains undiagnosed perhaps due to lack of facilities in mycology. [7] Currently, diagnosis of E. jeanselmei is achieved through the use of sequence data of the Internal Transcribed Spacer (ITS) region of ribosomal DNA (rDNA), which reflects the taxonomy of this group. [8]

Patients cured by medical treatment demonstrate many histological changes at the site of lesion, and that includes replacement of the neutrophils that usually surround the grains with lymphocytes and giant cells. Fibrosis is common in the mycetoma lesion and granuloma formation with type 3 tissue reaction is indicative of complete cure. [9] Surgery may be required in protracted cases because most of the drugs do not penetrate the infected tissues adequately to eradicate the causative organism. [3]

The management of mycetoma is highly challenging for the clinicians. For eumycetoma, Ketoconazole or Itraconazole is used. Conventional and liposomal formulations of Amphotericin B is recommended for eumycetoma caused by Madurella and Fusarium species. [3]

In this case, the lesion was excised and the patient was successfully treated with Ketoconazole. In conclusion, greater awareness of the disease on the part of the clinician is needed to suspect and investigate for mycotic etiology, especially in the absence of response to antibacterial therapy.

 
  References Top

1.
Hay RJ. Agents of eumycotic mycetomas. In: Topley and Wilsons Microbiology and Microbial Infections. Medical Mycology. 10 th ed. Baltimore: Hodder Arnold; 2007. p. 385-95.  Back to cited text no. 1
    
2.
Mahgoub ES. Agents of Mycetoma. In: Mandell Douglas and Bennets Principles and Practice of infectious diseases. 4 th ed., Vol. 2, Chap. 242. New York: Churchill Livingstone; 1995. p. 2327-30.  Back to cited text no. 2
    
3.
Chander J. A textbook of Medical Mycology. 3 rd ed. Chap. 11. New Delhi: Mehta Publishers; 2009. p. 158.  Back to cited text no. 3
    
4.
Hemashettar BM, Patil CS, Nagalotimath SJ, Thammayya A. Mycetoma due to Exophiala jeanselmei (a case report with description of the fungus). Indian J Pathol Microbiol 1986;29:75-8.  Back to cited text no. 4
    
5.
Maiti PK, Ray AA, Bandopadhyay S. Epidemiological aspects of mycetoma from a retrospective study of 264 cases in West Bengal. Trop Med Int Health 2002;7:788-92.  Back to cited text no. 5
    
6.
Sartoris KE, Baillie GM, Tiernan R, Rajagopalan PR. Phaeohyphomycosis from Exophiala jeanselmei with concomitant Nocardia asteroids infection in a renal transplant recipient: Case report and review of the literature. Pharmacotherapy 1999;19:995-1001.  Back to cited text no. 6
    
7.
Chakrabarti A, Singh K. Mycetoma in Chandigarh and surrounding areas. Indian J Med Microbiol 1998;16:64-5.  Back to cited text no. 7
    
8.
Desnos-Ollivier M, Bretagne S, Dromer F, Lortholary O, Dannaoui E. Molecular identification of black grain mycetoma agents. J Clin Microbiol 2006;44:3517-23.  Back to cited text no. 8
    
9.
Fahal AH, el Toum EA, el Hassan AM, Mahgaub ES, Gumaa SA. The host tissue reaction to Madurella mycetomatis: New classification. J Med Vet Mycol 1995;33:15-7.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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