2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
3 Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
4 Department of Mycology, All India Institute of Medical Sciences, New Delhi, India
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi - 110 029
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Ramam M, Bhat R, Garg T, Sharma VK, Ray R, Singh M K, Banerjee U, Rajendran C. Author's reply. Indian J Dermatol Venereol Leprol 2008;74:168
We thank Dr. Joshi for his interest in our paper and his thoughtful comments about the management of actinomycetomas. There is a great need for more sensitive diagnostic tests that will confirm the presence of mycetoma. Although the clinical presentation is characteristic in many cases, laboratory diagnosis is required to know if mycetoma is eumycotic or actinomycotic. In addition, identification of the organism causing actinomycetoma may lead to better-directed therapy using drugs effective against the isolated bacterium.
Fortunately, many of the different organisms causing actinomycetoma are susceptible to the same drugs, making it possible to embark on treatment even if the antibiotic sensitivity of the causative organism is not known. While there are no randomized studies comparing monotherapy with combination therapy, observational studies show that the latter is more effective.  The usefulness of combination treatments was demonstrated in a fairly large group of 144 patients with actinomycetoma. In that study, the most effective combinations were streptomycin plus co-trimoxazole and streptomycin plus daspone.  Other studies in smaller groups of patients have also identified treatments useful in this disorder;  these combinations are likely to be effective in most patients. But clearly, more work is necessary.
It is true that admission to a hospital places financial strain on patients and may lead to drop-outs. However, in our study, all the drop-outs occurred after discharge from hospital. Nevertheless, admission can be avoided if gentamicin is injected intramuscularly in the intensive phase of the schedule described in our paper.  The pharmacokinetics of gentamicin after intravenous and intramuscular administration appear to be similar.  Since administration of the drug and monitoring for toxicity is familiar to medical practitioners, it may be possible for the patient to receive injections from any medical facility near his home. After 4 weeks, the patient can be switched to the maintenance phase, which requires oral medications alone.
The response to combination therapy with rifampicin and co-trimoxazole in the reported patient is impressive. If results are similar in a larger number of patients, it would be a useful addition to the treatments available for this neglected disease. Careful clinical evaluation and a chest X-ray to exclude concurrent tuberculosis would, of course, be mandatory to avoid inadvertently administering rifampicin monotherapy for tuberculosis in people who have both infections. 
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