Case Study: Inflamed foot cyst may be fungal tumor

Summary

Fungal infections are very common in India, especially tenia pedis and other superficial fungal infections. Mycetoma is a chronic granulomatous infective disease of the skin and related tissues,[5] predominantly seen in tropical countries, and it generally presents as superadded long-standing infections over already unhealthy skin or wounds. Common presentations are long-term, non-healing, discharging sinuses and confluence of necrotic grayish-white or pigmented nodules. However, it may present as a subcutaneous cyst like the woman described here. Ruling out other differential diagnoses and treatment are also important.

Background

Mycetoma is a disease that occurs mainly in regions in a narrow region north of the equator. It can be caused either by actinomycetoma bacteria or by eumycetoma fungi (typically madurella mycetomatis.) Traces of the fungus are found in the environment, but do not cause illness in most people who come in contact with it. [4]

Case Presentation

A 32-year-old female patient, a farmer by occupation, presented with swelling of the left heel region, with a healed sinus and a solitary painful cyst measuring 2.8 cm in diameter. She gave a history of sinuses in the left foot. The working diagnosis was a plantar epidermal cyst. The patient was otherwise fit and well, with no history suggestive of immunosuppression. She was not diabetic and was not on steroids or other medications.

Investigationspedal mycetoma fig1

  1. Routine blood examination: revealed eosinophilia (860/µl)
  2. Ultrasonography to assess the cyst; its contents and extension
  3. X-ray: to rule out underlying bone involvement
  4. Sonogram or dye-test to locate and assess the sinus
  5. Routine bacterial, fungal and AFB culture

Differential Diagnosispedal mycetoma fig2

  1. Parasitic cyst
  2. Epidermal inclusion cyst
  3. Tuberculosis
  4. Bursa
  5. Mycetoma or fungal tumor
  6. Ganglion
  7. Skin adnexal tumors or benign cystic lesions

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Treatment

Excision/debridement followed by itraconazole-based multi-drug therapy for 6 months. Major emphasis was on health education and the importance of wearing footwear.

Outcome and Follow-Up

The patient is doing well 9 months after surgery and medicines.

Discussion

Mycetoma typically occurs in young or middle-aged adults, usually due to puncture wounds when walking without shoes or sandals.[1] Bacteria or fungus can cause mycetoma in different regions.[2] Mycetoma can spread locally through soft tissues and bone, but presentation as an inflamed cyst had not been reported yet. An excision biopsy revealed granulomatous reaction to pigmented fungal balls (see photomicrographs 1 and 2), which confirmed the diagnosis and excluded all other possibilities.
Surgical excision with wide margins is the recommended treatment. Antifungal or antibiotic treatments have not been proven to be effective, but can also be used when the fungus or bacteria causing the lesion has been identified.[6] In this patient, the lesion was an isolated cyst and was excised with a wide margin, with no apparent local spread of the infection.

Learning Points/Take Home Messages

Non-healing pedal cyst with sinus: consider fungal tumor also!

About The Author

Dr-Swapan-Samanta-64x80
Dr. Samanta, MBBS, MD is currently a consultant at Suraksha diagnostic PVT. LTD. Kolkata, India for histopath, cytopath and hematology. His other interests are: oncopathology, bone marrow and neuropathology.

 

References (click to show/hide)

  1. Venkatswami S, Sankarasubramanian A, Subramanyam S. The Madura foot: looking deep. Int J Low Extrem Wounds 2012; 11:31-42.
  2. Rattanavong S, Vongthongchit S, Bounphamala K et al. Actinomycetoma in SE Asia: the first case from Laos and a review of the literature. BMC Infect Dis 2012; 12: 349.
  3. Fahal AH, Hassan MA. Mycetoma. Br J Surg 1992; 79:1138-41.
  4. Van Belkum A, Fahal A, van de Sande WW. Mycetoma caused by Madurella mycetomatis: a completely neglected medico-social dilemma; Adv Exp Med Biol. 2013; 764:179-89.
  5. Gooptu S, Ali I, Singh G, Mishra RN. Mycetoma foot; J Family Community Med. 2013 May; 20(2):136-8. doi: 10.4103/2230-8229.114775. http://www.ncbi.nlm.nih.gov/pubmed/23983567
  6. Abdulkareem IH, Tellisi N, Harris NJ. Pedal mycetoma mimicking plantar fibroma: A case report Hard Tissue 2013 May 20; 2(3):30. http://www.oapublishinglondon.com/article/546


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