Recalcitrant eumycetoma of the foot: Financial burden a major barrier on the road of recovery

Abstract

Eumycotic mycetoma has been recently included in the World Health Organization’s list of neglected tropical diseases. It is the first fungal infection to get such significant attention by the international health community. The disease is distributed worldwide, with majority of cases reported from tropical and subtropical countries like India, Mexico and Sub-Saharan areas of Africa. However, due to chronic course of disease or lack of adequate medical services, the reported cases represent only the tip of iceberg. In addition to this, even after diagnosing the disease on time, successful outcomes are further hampered by various factors like duration, cost, toxicity, and compliance to treatment. We report a case of refractory eumycetoma who initially responded to the therapy but interruption due to financial constraints led to worsen-ing of lesions and, finally, ending into amputation. A 30-year-old male resident of Rajasthan, India, presented to our Dermatology outpatient department with complaint of recurrent swelling on the left sole with multiple discharging sinuses. A small papule developed 15 years back, which slowly increased in size associated with bloody discharge and black granules. The patient could not recall any history of trauma. Due to recurrent episodes, multiple surgical excisions were performed providing temporarily relief only. He was then referred to our hospital, which is the apex health care institute of India. Grains collected from discharging sinuses were 1 mm to 2 mm, hard in consistency, crushed, and subjected to microscopy and culture. The potassium hydroxide (KOH) mount of discharge with black grains did not reveal any fungal elements. However, the KOH-calcofluor staining showed the presence of septate hyphae, and Madurella sp. grew on culture. Despite on itraconazole and terbinafine therapy, recurrence occurred after 5 months, with repeat culture also growing Madurella sp. Surgical excision was done, and posaconazole was added along with continuation of terbinafine. The patient showed clinical improvement after eleven months of treatment, after which he stopped treatment due to financial constraints. The lesions recurred within the following months, and he finally had to undergo amputation. Management of recurrent cases with newer potent antifungal, such as posaconazole, should be considered early in the course of the disease. Financial burden, prolonged duration, tolera-bility, and compliance with medical therapy are issues which need to be addressed. Such patient and their kin should be counseled for completing the regimen in spite of high cost of the drugs as it might prevent amputation, which in turn might affect their livelihood.