Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Review Article
ARTICLE IN PRESS
doi:
10.25259/IJDVL_615_2021

An overview of mycetoma and its diagnostic dilemma: Time to move on to advanced techniques

Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Department of Dermatology, Venereology, and Leprosy, King George’s Medical University, Lucknow, Uttar Pradesh, India
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Department of Microbiology, King George’s Medical University, Lucknow, Uttar Pradesh, India
Corresponding author: Dr. Uneza Husain, Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. uneza47@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Husain U, Verma P, Suvirya S, Priyadarshi K, Gupta P. An overview of mycetoma and its diagnostic dilemma: Time to move on to advanced techniques. Indian J Dermatol Venereol Leprol doi: 10.25259/IJDVL_615_2021

Abstract

The neglected tropical disease mycetoma can become extremely devastating, and can be caused both by fungi and bacteria; these are popularly known as eumycetoma and actinomycetoma respectively. The classical triad of the disease is subcutaneous swelling, multiple discharging sinuses and the presence of macroscopic granules. The present study aims to highlight the existing diagnostic modalities and the need to incorporate newer and more advanced laboratory techniques like pan fungal/pan bacterial 16S rRNA gene polymerase chain reaction (PCR) and sequencing, Matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS), rolling circle amplification (RCA), loop-mediated isothermal amplification (LAMP) and recombinase polymerase amplification (RPA). It is important for the medical team to be aware of the various diagnostic options (both existing and future), so that diagnosis of such a debilitating disease is never missed, both by clinicians and microbiologists/pathologists. The newer diagnostic methods discussed in this article will help in rapid, accurate diagnosis thus facilitating early treatment initiation, and decreasing the overall morbidity of the disease. In the Indian context, newer technologies need to be made available more widely. Making clinicians aware and promoting research and development in mycetoma diagnostics is the need of the hour.

Keywords

Mycetoma
laboratory diagnosis
MALDI-TOF
PCR
rolling circle amplification
loop-mediated isothermal amplification
recombinase polymerase amplification

Introduction

Mycetoma is a disfiguring, granulomatous neglected tropical disease said to be caused by either bacteria (actinomycetoma) or fungi (eumycetoma). In 1842, John Gill gave the first description of mycetoma in India at Madurai.1,2 Maximum cases have been reported from the ‘mycetoma belt’ which includes equatorial regions of Africa, Latin America and Asia including India. In India maximum cases have been reported from Rajasthan and South India.3 Prevalence of actinomycetoma is more in the southern part of India, southeast Rajasthan, along with Chandigarh, while eumycetoma is found to be more predominant in North India and desert regions of central Rajasthan.3 Sawatkar et al. reported seven cases of actinomycetoma and four eumycetoma cases out of a total of 11 cases in a year (2015-2016) from Nagpur, Maharashtra supporting the evidence that actinomycetoma is more common than eumycetoma in this region.4 Padhi et al. identified Actinomadura madurae and Madurella mycetomatis to be the most common agents of mycetoma in their case series.5 Bakshi et al. also reported Madurella mycetomatis as the most frequent etiological agent of eumycetoma.6 In contrast to the above studies, Dubey et al. (2019) reported Aspergillus flavus, Aspergillus nidulans, Fusarium solani, Sarocladium kiliense, Curvularia lunata as the predominant agents of eumycetoma in New Delhi, India.3 People of all age groups can be affected, the most common being young adults between 20 and 40 years.7-11 This is the most active age group involved in various outdoor activities and hence the disease should not be neglected in any case. The male: female ratio was found to vary between 3:1 and 5:1 in different studies.9,11,12 The disease tends to occur in poor communities in remote areas. Lack of education and awareness of the disease, along with its painless nature, adds to the burden, as amputation is the only solution in such cases if left untreated.

Etiopathogenesis

Infection occurs in humans by the entry of organisms from the soil into subcutaneous tissue through repeated trauma, penetrating injury or breach of the skin by thorn prick. The foot is considered to be the most common site, others being hands, shoulder, abdomen, buttocks and scalp. While eumycetoma is slowly progressive and well encapsulated, actinomycetoma is characterised by a more rapid course, inflammation and destruction. The incubation period varies from 3 months to 9 years.13 The classical triad of the disease is subcutaneous swelling, multiple discharging sinuses and the presence of macroscopic granules within discharging sinuses. The various causative organisms and the corresponding appearance of grains have been described in Table 1.12,14-17 Once the organism enters the skin, it resides in micro abscesses formed by polymorphonuclear cells. The disease is characterised by the presence of large filamentous aggregates of causative organisms which are the centre of its inflammatory activity. The disease may take the most devastating form by the involvement of muscle and bone, causing osteosclerotic/osteolytic lesions if no treatment is initiated at an appropriate time.

Table 1:: Aetiological agents of mycetoma and corresponding appearance of grains12,14,17
Eumycetes Actinomycetes
Organism Colour of grains Organism Colour of grains Organism Colour of grains
Trematosphaeria (Madurella) grisea Black Cylindrocarpon cyanescens White Streptomyces somaliensis Yellow/
brown
Madurella mycetomatis Black Cylindrocarpon destructans White Actinomadura madurae White/yellow/pink
Aspergillus nidulans White Leptosphaeria senegalensis Black Actinomadura pelletieri Red
Exophiala jeanselmei Black Leptosphaeria thompkinsii Black Actinomyces israelii White/
yellow
Pseudallescheria boydii White Polycytella hominis White Nocardia asteroides White
Fusarium oxysporum White Pseudochaetosphaeronema larense Black Nocardia brasiliensis White
Fusarium solani White Pyrenochaeta mackinnonii Black Nocardia caviae White/
yellow
Fusarium moniliforme White Pyrenochaeta romeroi Black Nocardia farcinica White/
yellow
Phialophora verrucosa Black Neotestudina rosatii White Nocardia transvalensis White
Aspergillus flavus Green Plenodomus avramii Black Nocardia dassonvillei Cream
Curvularia geniculata Black Acremonium falciforme White
Curvularia lunata Black Acremonium kiliense White
Corynespora cassiicola Black Acremonium recifei White

Laboratory Diagnosis

Gross examination, microscopy and culture

The specimen is collected by pressing the sinus from suspected lesions to collect grains which are then subjected to gross examination, microscopy and culture. The gross examination includes an assessment of the colour, size, shape and texture of grains. For example, black grains are suggestive of eumycetoma, and red grains are seen in Actinomadura pelletieri. Grains of Nocardia asteroides and Nocardia brasiliensis are smaller in size while large-sized grains are observed in Madurella spp. and Actinomadura madurae. Grains harbouring Streptomyces somaliensis and Madurella mycetomatis can be hard in consistency though grains of other pathogens are mostly soft in consistency.18,19

The various techniques of microscopic examination include Gram stain, modified Ziehl Neelsen (Z-N), or haematoxylin and eosin (H and E) stain for actinomycetoma and potassium hydroxide (KOH) mount, histopathological stains like H and E, Gomori’s methenamine silver (GMS) or periodic acid Schiff (PAS) stains for eumycetoma. In 2009, Alam et al. reported five cases of mycetoma from India presenting with ulcers/purulent discharge admixed with black granules. Haematoxylin and eosin stained sections and Gram stain showed thin filamentous bacteria (actinomycetoma) and thick club-shaped structures (eumycetoma).18

Culture is required to identify the organism properly, as morphological features of grains can be similar in many of the agents causing mycetoma. The various culture media required are Sabouraud Dextrose Agar with and without antibiotics, 5% sheep blood agar, brain heart infusion agar, Lowenstein Jensen media in multiple sets. Each set of culture media is incubated at both 25°C and 37°C and observed for growth which occurs usually after 7-10 days,20 though delayed growth may be observed especially in case of fungal pathogens, hence culture media needs to be incubated for 4-6 weeks before reporting it as negative.19 Padhi et al. detected 13 cases of mycetoma by histopathological examination but in only 8 /13 cases growth was seen on culture (though in 1/5 of remaining cases, culture was not done).5 A flowchart of routine diagnostic workup is demonstrated in Figure 1 which can be done in resource-poor settings with no access to molecular facilities.2

Figure 1:: Diagnostic algorithm for mycetoma2

Cytodiagnosis

Cell block technique can provide us with the combined advantages of routine histopathology and fine needle aspiration (FNA) direct smears. Aspirated material from suspected lesions can be used to prepare a fixed cell block. This technique is described as safe, rapid, and effective by Yousif et al. in a study done on 240 patients.21 The authors reported sensitivities of 85.7% and 87.5% for actinomycetoma and eumycetoma, respectively utilising this technique and there was no difference statistically in the findings obtained by the histopathological sections and cell block. The cell blocks have the added advantage of being stored for the prolonged duration for future studies and hence provide a ray of hope for researchers working on mycetoma.

Mycetoma Research Centre of the University of Khartoum, Sudan conducted a study using FNA from lesions for the identification of grains and tissue reaction. Surgical biopsies and histopathological examinations were performed if FNA was found to be negative in a suspicious case. In the study, 3177 (47%) patients underwent FNA for cytological examination and the findings were compatible with Madurella mycetomatis in 2379 (75%) cases, Actinomadura madurae in 316 (10%) cases, Streptomyces somaliensis in 277 cases (7%), Actinomadura pelletieri was uncommon and was detected in 39 (1%) cases.22

Radiology

Extension of the lesions in bone and other tissues can be determined by magnetic resonance imaging (MRI), X-rays, and tomography.23 In MRI, ‘dot in circle’ is a radiologically relevant sign of mycetoma.24 This sign is described as hypointense foci within the hyperintense spherical lesions that comprise granulomatous tissue surrounding fungal elements/bacterial colonies. Limited availability of MRI and lack of expertise are hindrances in diagnosis, especially in rural areas where the disease is prevalent. In the context of ultrasonographic findings, thick-walled cavities with hyper-reflexive echoes representing grains may be seen in eumycetoma while in actinomycetoma fine, closely aggregated hyperechoic foci are seen at the bottom of rounded lesions.19

Serology

Serological tests are of limited value in the diagnosis of mycetoma as most of the tests utilise cell extracts instead of exoantigens and cross-reaction can occur with other diseases. The various serological methods that have been used are the complement fixation test, immunodiffusion, counter-immunoelectrophoresis, western blot and enzyme-linked immunosorbent assays.2

Molecular diagnosis

Though molecular techniques are heading towards advancement in routine diagnosis of mycetoma, these are costly methods and still lack standardisation in many laboratories. These methods can also be used for epidemiological studies and generating accurate therapeutic options thus minimising the use of combination drugs. In 2017, Bitan et al. reported four new cases from Israel and also documented 17 other case reports between 1942 and 2015 from the same place. They included pan-fungal polymerase chain reaction (PCR) according to the protocol described in http://sites.biology.duke.edu/fungi/mycolab/primers.htm and pan bacterial PCR (16S rRNA gene PCR and sequencing) in diagnosis apart from conventional methods.25 Out of four, two culture-negative cases were successfully detected by PCR.

Rolling circle amplification (RCA) that uses species-specific padlock probes, loop-mediated isothermal amplification (LAMP) and recombinase polymerase amplification (RPA) proved to be highly useful techniques for the diagnosis of mycetoma in studies done by Ahmed et al. 26,27 The basic methodology of RCA involves the detection of specific sequences of nucleic acid and enzymatic amplification of circularised oligonucleotide probes under isothermal conditions.28 It is a highly specific, simple, rapid, single-day protocol and is of low cost. Sixty-two isolates were identified by Ahmed et al. utilising the RCA technique and the results were 100% specific with zero cross reactivity.27 The major limitations of RCA are the culture of the pathogen and the requirement of PCR amplification.26,27

LAMP technique relies on the utilisation of four primers that identify six regions in the target DNA, followed by amplification via auto-cycling and strand displacement with a specialised DNA polymerase.29-31 RPA is another rapid detection isothermal technique which can be utilised in places where mycetoma is endemic. The risk of contamination was reported to be lower than LAMP by Ahmed et al. Both RPA and LAMP techniques (sensitivity and specificity=100%) were found to be equal in performance to PCR in detecting Madurella mycetomatis directly from clinical samples.26

MALDI-TOF MS (Matrix-Assisted Laser Desorption/Ionization-Time of Flight mass spectrometry)

MALDI-TOF MS is a high throughput proteomic technique that requires co-crystallisation of an analyte with a matrix that absorbs laser striking it and converts the analyte molecules into the gas phase. The ions thus formed, travel, and reach the detector at a speed inversely proportional to their mass/charge (m/z) ratio. A signal is created indicating m/z ratio (x -axis) and ion intensity (y -axis), according to the time taken to hit the detector by each of the ion particles.32 By incorporating this method, rapid and accurate identification of etiological agents of eumycetoma is possible thus eliminating the need to wait for culture reports. Fraser et al. tested 57 organisms corresponding to 10 different species from confirmed cases of subcutaneous pedal masses and eumycetoma, identified previously by PCR amplification and sequencing of Internal Transcribed Spacer 1 (ITS 1). They demonstrated accurate identification of all of the test organisms with the help of this technique, obtaining log scores more than 1.8, 1.9 and 2.0, in 100%, 90.4% and 67.3% of isolates respectively.33 Recently, dermatophytic mycetoma of scalp was reported by Diongue et al. which is a rare condition. The causative organism was identified as Microsporum audouinii (atypical strain) by MALDI-TOF MS with a Biotyper score of 2.022. They further confirmed the organism by nucleotide sequence analysis of the ITS region of the rRNA gene.34

MALDI-TOF MS is less labour-intensive, more cost-effective, and gives faster results in approximately 1 day, as compared to partial (500-bp) 16S rRNA gene sequencing. Buckwalter et al. were able to detect Nocardia species (90%) and other aerobic actinomycetes (51%) by MALDI-TOF with the help of a custom enhanced library, and some additional processing steps.35

While utilising MALDI-TOF technique in the identification of genus Nocardia, spectra adequate for identification cannot be obtained using only processes for general bacteria because their cell wall contains aliphatic acid such as mycolic acid, hence Segawa et al. proposed another method, Nocardia extraction method in Department of Clinical Laboratory at Chiba University Hospital (NECLC). In this method, the ethanol-formic acid extraction technique is utilised, silica beads are added as a part of the high-temperature extraction method, and extraction of formic acid is done within 10 minutes.36

The various advantages and disadvantages of different techniques used in the diagnosis of mycetoma are summarised in Table 2.2,7,13,18,21,26,27,35-38 Recently, an interesting survey was done by Hay et al. based on responses given by 23 clinicians and mycologists on the diagnostic techniques of fungal neglected tropical diseases. Percentage positive response of participants regarding the optimal diagnostic method in well-equipped settings versus diagnostic methods of use in peripheral clinics and laboratories for mycetoma (in terms of percentage) is depicted in Table 3.39 In the Indian context, newer technologies are not available everywhere and much needs to be done in this field. Making clinicians aware and promoting research and development in mycetoma diagnostics is important in the current situation.

Table 2:: Advantages and disadvantages of different techniques used in the diagnosis of mycetoma2,7,13,18,21,26,27,35-38
Advantages Disadvantages
Direct Microscopy Simple, inexpensive, rapid, differentiate between actinomycetoma and eumycetoma. Low sensitivity and specificity
Histology Suppurative granuloma. Neutrophilic infiltrate, palisading histiocytes, eosinophil, lymphocytes, macrophages, fibrosis, multinucleated giant cell (occasional).
Eumycetoma = hyphae, thick club-shaped structures, embedded in cement like matrix
Actinomycetoma = multilobated colonies, pale central eosinophilia, basophilic outer border with ill-defined branching filaments
Need expertise
Cell block technique Cost-effective, rapid, general/spinal anaesthesia not required, cell blocks can be preserved for a long period Pain in patients with a low pain threshold
Culture Identification of causative organisms. Results may be delayed
(Time-consuming)
Serology Detection of circulating antibodies may help in guiding management. Chances of cross-reactivity, of limited value
Radiodiagnosis Differentiate between actinomycetoma and eumycetoma
Characteristic features like ‘dot in circle’ sign can be seen.
The extent of the disease can be assessed.
Limited availability of MRI in peripheral areas.
Need expertise.
Molecular Can identify the specific organism
up to species level.
Lack of standardisation in many places
PCR and sequencing High sensitivity and specificity.
Clinical samples can be directly used.
Costly compared to other newer molecular techniques.
DNA extraction required.
RCA Highly specific, rapid single-day protocol. Culture and DNA extraction required, sensitivity is low.
RPA and LAMP Culture not required.
Thermal cycler not required.
It can be used for point of care testing, turnaround time = 3 hrs.
High sensitivity and specificity.
DNA extraction required.
Mass spectrometry(MALDI-TOF MS) Accurate, less labour-intensive, faster results possible, economical (though the initial cost of a mass spectrometer is high, the cost of identifying one species is low compared to molecular methods). May require some additional processing steps for agents of mycetoma compared to routine identification, the enhanced database needed.

Abbreviations: MRI = Magnetic resonance imaging, PCR = Polymerase chain reaction, RCA = Rolling circle amplification, RPA = Recombinase polymerase amplification, LAMP = Loop-mediated isothermal amplification, MALDI-TOF MS = Matrix-assisted laser desorption/ionization-time of flight mass spectrometry

Table 3:: Percentage positive response of participants regarding the optimal diagnostic method in well-equipped settings versus diagnostic methods of use in peripheral clinics and laboratories in case of mycetoma39 [Hay et al., 2019]
Diagnostic method Positive response (%)
Well-equipped settings Resource limited settings
Clinical features 92% 96%
Direct microscopy 88% 88%
Histopathology 88% 43%
Culture 96% 33%
Serology 8% __
Molecular diagnosis 71% 13%
Other Imaging, dermoscopy Imaging

Conclusion

Despite diagnostic techniques having evolved from microscopy to molecular, there are still complexities concerning the diagnosis and treatment of the devastating disease mycetoma. Though eumycetoma and actinomycetoma have subtle differences in clinical presentations, their treatment protocols are completely different. Early and accurate diagnosis is extremely beneficial in optimising treatment, hence teamwork between clinicians, microbiologists and pathologists is the need of the hour.

Key points of the review include limitations of the newer techniques

  1. Microscopy is relevant and irreplaceable for a basic workup to differentiate Actinomycetoma from Eumycetoma.

  2. Teamwork between clinicians, microbiologists and pathologists have to be strengthened as it plays a vital role in the diagnosis of mycetoma.

  3. Molecular methods can make the diagnosis easy, timely and definite. Hence it will help the clinicians to avoid prescribing combination drugs, thus helping to fight emerging resistance.

  4. Newer diagnostic methods like MALDI-TOF, can accurately diagnose various pathogens causing mycetoma but are still sidelined and not being incorporated at places with good access to laboratory facilities.

  5. The newer techniques are mainly limited by the cost, especially in resource-poor regions where mycetoma is more common.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

List of Abbreviations

PCR: Polymerase chain reaction

MALDI-TOF MS: Matrix-assisted laser desorption/ionization-time of flight mass spectrometry

RCA: Rolling circle amplification

LAMP: Loop-mediated isothermal amplification

RPA: Recombinase polymerase amplification

Z-N: Ziehl-Neelsen

H and E: Haematoxylin and eosin

KOH: Potassium hydroxide

GMS: Gomori’s methenamine silver

PAS: Periodic acid-Schiff

FNA: Fine needle aspiration

MRI: Magnetic resonance imaging

m/z: Mass-to-charge ratio

ITS 1: Internal Transcribed Spacer 1

NECLC: Nocardia extraction method in Department of Clinical Laboratory at Chiba University Hospital

References

  1. , , , , . Eumycetoma. Clin Dermatol. 2012;30:389-96.
    [CrossRef] [PubMed] [Google Scholar]
  2. . Mycetoma In: Textbook of Medical Mycology (4th ed.). In New Delhi: Jaypee Brothers Medical Publishers; . p. 203-19.
    [Google Scholar]
  3. , , , , , , et al. Epidemiological profile and spectrum of neglected tropical disease eumycetoma from Delhi, North India. Epidemiol Infect. 2019;147:e294.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , , . Mycetoma: A common yet unrecognized health burden in central India. Indian Dermatol Online J. 2019;10:256-61.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , , , , , et al. Mycetoma in south India: Retrospective analysis of 13 cases and description of two cases caused by unusual pathogens: Neoscytalidium dimidiatum and Aspergillus flavus. Int J Dermatol. 2010;49:1289-96.
    [CrossRef] [PubMed] [Google Scholar]
  6. , . Incidence and changing pattern of mycetoma in western Rajasthan. Indian J Pathol Microbiol. 2008;51:154-5.
    [CrossRef] [PubMed] [Google Scholar]
  7. , , , , . Mycetoma: A clinical dilemma in resource limited settings. Ann Clin Microbiol Antimicrob. 2018;17:35.
    [CrossRef] [PubMed] [Google Scholar]
  8. , , , , , . Mycetoma: A unique neglected tropical disease. Lancet Infect Dis. 2016;16:100-12.
    [CrossRef] [PubMed] [Google Scholar]
  9. , , , , , , et al. Mycetoma: Experience of 482 cases in a single center in Mexico. PLoS Negl Trop Dis. 2014;8:e3102.
    [CrossRef] [Google Scholar]
  10. , , , , , , et al. Management of mycetomas in France. Med Mal Infect. 2013;43:286-94.
    [CrossRef] [PubMed] [Google Scholar]
  11. , . Mycetomas: An epidemiological, etiological, clinical, laboratory and therapeutic review. An Bras Dermatol. 2018;93:8-18.
    [CrossRef] [PubMed] [Google Scholar]
  12. , . Mycetoma: A review. Am J Clin Dermatol. 2006;7:315-21.
    [CrossRef] [PubMed] [Google Scholar]
  13. , , , . Mycetoma: An update. Indian J Dermatol. 2017;62:332-40.
    [CrossRef] [PubMed] [Google Scholar]
  14. , , , , , . Mycetoma caused by Madurella mycetomatis: A neglected infectious burden. Lancet Infect Dis. 2004;4:566-74.
    [CrossRef] [Google Scholar]
  15. , , , . Deep fungal infections In: , , , eds. Fitzpatrick’s dermatology in general medicine (5th ed.). In ed. Vol. 2. New nation of medical treatments New York: McGraw-Hill; . p. 2372-7.
    [Google Scholar]
  16. , , , . Subcutaneous fungal infections. Dermatol Ther. 2004;17:523-31.
    [CrossRef] [PubMed] [Google Scholar]
  17. , . Mycetoma In: , , , eds. Dermatology. Vol Vol. 1. In ed. New York: Mosby; . p. :1187-8.
    [Google Scholar]
  18. , , , , , . Histological diagnosis of madura foot (mycetoma): A must for definitive treatment. J Glob Infect Dis. 2009;1:64-7.
    [CrossRef] [PubMed] [Google Scholar]
  19. , . Mycetoma: Reviewing a neglected disease. Clin Exp Dermatol. 2019;44:123-29.
    [CrossRef] [PubMed] [Google Scholar]
  20. , , . Mycetoma. Clin Dermatol. 2007;25:195-02.
    [Google Scholar]
  21. , , . A new technique for the diagnosis of mycetoma using fixed blocks of aspirated material. Trans R Soc Trop Med Hyg. 2010;104:6-9.
    [CrossRef] [PubMed] [Google Scholar]
  22. , , , . Mycetoma in the Sudan: An update from the Mycetoma Research Centre, University of Khartoum, Sudan. PLoS Negl Trop Dis. 2015;9:e0003679.
    [CrossRef] [PubMed] [Google Scholar]
  23. , , , . Eumycetoma due to Madurella mycetomatis from two cases of black grain mycetoma in Morocco. Journal de mycologie médicale. 2011;21:281-4.
    [CrossRef] [Google Scholar]
  24. , , , . “Dot in Circle” sign in actinomycotic mycetoma on MRI and ultrasound− A case series. MAMC Journal of Medical Sciences. 2019;5:145.
    [CrossRef] [Google Scholar]
  25. , , , . Mycetoma (Madura Foot) in Israel: Recent cases and a systematic review of the literature. Am J Trop Med Hyg. 2017;96:1355-61.
    [CrossRef] [PubMed] [Google Scholar]
  26. , , , , , . Application of isothermal amplification techniques for identification of Madurella mycetomatis, the prevalent agent of human mycetoma. J Clin Microbiol. 2015;53:3280-5.
    [CrossRef] [PubMed] [Google Scholar]
  27. , , , , . Rapid identification of black grain eumycetoma causative agents using rolling circle amplification. PLoS Negl Trop Dis. 2014;8:e3368.
    [CrossRef] [Google Scholar]
  28. , . DNA replication: The rolling circle model. Cold Spring Harb Symp Quant Biol. 1968;33:473-84.
    [CrossRef] [PubMed] [Google Scholar]
  29. , , , , . Loop-mediated isothermal amplification (LAMP): A versatile technique for detection of micro-organisms. J Appl Microbiol. 2018;124:626-43.
    [CrossRef] [PubMed] [Google Scholar]
  30. , , , , , , et al. Loop-mediated isothermal amplification of DNA. Nucleic Acids Res. 2000;28:E63.
    [CrossRef] [PubMed] [Google Scholar]
  31. , , , , , , et al. Applications of loop-mediated isothermal DNA amplification. Appl Biochem Biotechnol. 2011;163:845-50.
    [CrossRef] [PubMed] [Google Scholar]
  32. , , . Mass spectrometry-based proteomic profiling of lung cancer. Proc Am Thorac Soc. 2009;6:159-70.
    [CrossRef] [PubMed] [Google Scholar]
  33. , , . Rapid and robust identification of the agents of black-grain mycetoma by matrix-assisted laser desorption ionization-time of flight mass spectrometry. J Clin Microbiol. 2017;55:2521-28.
    [CrossRef] [PubMed] [Google Scholar]
  34. , , , , , , et al. Dermatophytic mycetoma of the scalp due to an atypical strain of Microsporum audouinii identified by MALDI-TOF MS and ITS sequencing. J Mycol Med. 2019;29:185-8.
    [CrossRef] [PubMed] [Google Scholar]
  35. , , , , , , et al. Evaluation of matrix-assisted laser desorption ionization-time of flight mass spectrometry for identification of Mycobacterium species, Nocardia species, and other aerobic Actinomycetes. J Clin Microbiol. 2016;54:376-84.
    [CrossRef] [PubMed] [Google Scholar]
  36. , , , , , , et al. Identification of Nocardia species using matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry. Clin Proteomics. ;12:6.
    [CrossRef] [PubMed] [Google Scholar]
  37. , , . An approach to histology-based diagnosis and treatment of Madura foot. J Infect Dev Ctries. 2012;6:684-8.
    [CrossRef] [PubMed] [Google Scholar]
  38. , , . Matrix-assisted laser desorption ionization-time of flight (maldi-tof) mass spectrometry for detection of antibiotic resistance mechanisms: From research to routine diagnosis. Clin Microbiol Rev. 2013;26:103-14.
    [CrossRef] [PubMed] [Google Scholar]
  39. , , , , , , et al. The diagnosis of fungal neglected tropical diseases (fungal NTDs) and the role of investigation and laboratory tests: An expert consensus report. Trop Med Infect Dis. 2019;4:122.
    [CrossRef] [PubMed] [Google Scholar]
Show Sections