Transactions of the Royal Society of Tropical Medicine and Hygiene 106 (2012) 738–742

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Transactions of the Royal Society of

Tropical Medicine and Hygiene
journal homepage: http://www.elsevier.com/locate/trstmh

New MRI grading system for the diagnosis and management of

mycetoma
M.E. EL Shamy a , A.H. Fahal b,∗ , M.Y. Shakir b , M.M.A. Homeida a
a
Radiology Department, Alzaytouna Specialist Hospital, Khartoum, Sudan
b
The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan

a r t i c l e i n f o a b s t r a c t

Article history: The management of patients with mycetoma depends on accurate identification of the
Received 1 April 2012 causative organisms and of the extent of disease involvement along the different tissue
Received in revised form 15 August 2012
planes. Disease involvement cannot accurately be assessed with the available diagnostic
Accepted 15 August 2012
tools, so in this study we set out to evaluate the effectiveness of MRI in the diagnosis
Available online 14 September 2012
and management of mycetoma. Forty-two patients with confirmed mycetoma had MRI
examination of the affected parts. A grading system, The Mycetoma Skin, Muscle, Bone
Keywords:
Mycetoma Grading System (MSMBS), was used to describe and grade disease severity on the basis of
MRI MRI findings. The logistic regression test was used to correlate the clinical and MRI find-
Grading system ings. The study showed that MRI can help in the diagnosis and management of mycetoma
Diagnosis patients. The dot-in-circle sign, conglomerated foci with low signal intensity and macro-
Management and micro-abscesses on a background of a hypointense matrix are all diagnostic of myce-
toma. In patients with mycetoma, the MSMBS can grade disease severity, compare patients
and help to manage them. Further studies are needed to determine to what extent the
grading system can be used to determine a patient’s prognosis.
© 2012 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd.
All rights reserved.

1. Introduction in destruction, deformity and loss of function (Figure 1A);

Mycetoma is a chronic, granulomatous, progressive and
destructive inflammatory disease.1,2 It usually involves
the subcutaneous tissue and most probably develops
after a traumatic inoculation of the causative organ-
ism. Mycetoma may be caused by true fungi or higher
bacteria and hence is usually classified into eumycetoma
and actinomycetoma, respectively.3 The triad of painless
subcutaneous mass, sinus formation and purulent and
sero-purulent discharge that contains grains is pathog-
nomonic of mycetoma.4 The disease commonly spreads
to involve the skin, deep structures and bone, resulting
occasionally it is fatal.5 Mycetoma has many medical and
socioeconomic impacts on patients, their families and the
community.6
The management of patients with mycetoma depends
on accurate identification of the causative organisms and
the site and extent of the disease.2 The available diagnos-
tic tools for mycetoma are numerous but invasive, and
they cannot accurately assess disease spread and tissue
involvement.3 Hence this study set out to describe the MRI
appearance of mycetoma and determine its value as a non-
invasive technique for identification of the type and extent
of a patient’s mycetoma.

2. Patients and methods

∗ Corresponding author. Tel.: +249 912 346702; fax: +249 183 771211.
E-mail addresses: ahfahal@hotmail.com, ahfahal@uofk.edu This prospective study was conducted at the Mycetoma
(A.H. Fahal). Research Centre, Soba University Hospital, University of

0035-9203/$ – see front matter © 2012 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.trstmh.2012.08.009
 M.E. EL Shamy et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 106 (2012) 738–742 739

Table 1
Distribution of MRI findings among the study population of 42 patients
with mycetoma seen at the Mycetoma Research Centre, Khartoum, Sudan,
according to the Mycetoma Skin, Muscle, Bone Grading (MSMB) System

Score MRI finding No. (%)

Skin and subcutaneous tissue

0 No skin or subcutaneous involvement 0 (0)
1 Obliteration of skin and fascial planes 2 (4.8)
2 Abscess formation 1 (2.4)
3 Formation of sinus tract without grains 6 (14.3)
4 Formation of sinus tract with grains 33 (78.6)
Total 42 (100)
Muscle
0 No muscle involvement 5 (11.9)
1 Muscle oedema 2 (4.8)
2 Formation of micro-abscess 25 (59.5)
3 Formation of macro-abscess 10 (23.8)
Total 42 (100)
Bone
0 No bone involvement 9 (21.4)
1 Bone oedema 14 (33.3)
2 Bone cavitation 11 (26.2)
3 Bone destruction 8 (19.1)
Total 42 (100)

Khartoum, in the period between April 2010 and December

2011. The study included 42 patients with confirmed
mycetoma. The diagnosis of mycetoma was established
by careful clinical interview and thorough general and
local clinical examinations. All patients had x-ray exami-
nation of the affected part in anteroposterior and lateral
views, ultrasonic examination of their lesions and fine-
needle aspiration (FNA) for cytology. Surgical biopsy was
performed to collect grains for culture identification and
for histopathological examination in most of the patients.
After informed consent all patients had MRI examina-
tion of the affected part. MRI examination was performed
using a 1.5T MRI scanner (Toshiba Medical Systems,
Tochigi, Japan). The sequences were obtained using a
phased-array surface coil and included fat-suppressed
T2-weighted and T1- and T2-weighted images. Intravenous
gadolinium contrast was administered.
A grading system, the Mycetoma Skin, Muscle, Bone
grading system (MSMBS), was used to describe and grade
the mycetoma severity on the basis of MRI findings
(Table 1).
The logistic regression test was applied to correlate the
clinical and MRI findings, using the statistical software
package SPSS V.18.

3. Results

The study included 32 males (76%) and 10 females (24%).

Their ages ranged between 16 and 70 years, with a mean
of 33.7±17.5 years. Disease duration was 1–40 years, mean

Figure 1. (A) Extensive actinomycetoma involving the anterior abdom-
inal wall and thigh, with intra-abdominal extension. (B) Coronal
T2-weighted MR image of the same patient’s right upper thigh and
pelvis, showing extensive inflammatory mass with predominant bright
signal intensity granulomatous tissue (long arrow). Note the intra-pelvic
extension displacing the urinary bladder (short arrow) to the left, and
the small, spherical hyperintense lesions separated by tissue of low sig-
nal intensity. Some of these lesions show central tiny hypointense foci,
resulting in the dot-in-circle sign (curved arrow). (C) Axial T2-weighted
MR image of the same patient’s upper thigh, showing multiple spheri-
cal hyperintense lesions infiltrating the muscles (short arrows). Multiple
central tiny hypointense foci are noted (curved arrow).
740 M.E. EL Shamy et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 106 (2012) 738–742

Figure 2. Sagittal T2 MR image with fat saturation of a patient’s foot, Figure 3. Coronal T2-weighted fat saturation image of eumycetoma in the
showing an extensive eumycetoma lesion infiltrating and obliterating the foot; a spherical hyperintense lesion is surrounded has a low-signal sur-
subcutaneous tissue plane. A skin sinus (long arrow) contains low-signal rounding rim and a central hypointense focus (dot-in-circle sign) (arrow).
fungal grains. Note also multiple low signal intensity fungal grains (short
arrow), bone marrow oedema (curved arrow) and a dot-in-circle sign
(arrow head). most patients, with or without low-signal mycetoma grains
(Figure 2).
8.8±8.1 years. The foot was affected in 25 patients (60%); Muscle infiltration was seen as muscle oedema on fat-
this was the most commonly affected part, followed by the suppressed images or muscle infiltration with soft tissue
leg and knee (six patients; 14%), hand and gluteal region abscesses. Two types of abscess were seen: microabscesses
(for each, three patients affected [7%]), anterior abdominal of <1 cm diameter and macroabscesses of >1 cm in diameter
wall (two patients; 5%) and the thigh, forearm, head and (Figures 1C, 4). Signs of bone infiltration included extensive
neck (each affected in one patient; 2%). Most of the patients bone cavities containing low-signal mycetoma grains or
(69%) had massive lesions more than 10 cm in diameter. just early bone marrow oedema on fat-suppressed images
The majority of patients (89%) had active or healed sinuses. (Figure 2).
In 74% of them, the lesions were painless and 66% of them In most of the actinomycetoma patients, MRI showed
had recurrent disease. soft tissue microabscesses, bony periosteal reaction and
All patients had x-ray examination of the affected parts reactive sclerosis, whereas soft tissue macroabscesses,
and the findings were as follows: soft tissue swellings
(6/42, 14%), periosteal reaction (1/42, 2%), bone destruc-
tion (2/42, 5%) and combined findings (15/42, 36%); the
remaining patients (18/42, 43%) had no abnormal findings
on x-ray. The diagnosis was confirmed by histopatholog-
ical examination of the surgical biopsies or lesion FNA
and the cell-block technique, or both. The diagnosis of
eumycetoma caused by Madurella mycetomatis was con-
firmed in 24 patients (57%) and actinomycetoma caused by
Streptomyces somaliensis in 18 patients (43%).
In most patients, MRI examination revealed an ill-
defined lesion of abnormal signal intensity extending
from the subcutaneous tissue plane and infiltrating the
underlying muscle and bone planes. The lesions showed
predominant bright signal intensity on fat-suppressed
T2-weighted images of granulomatous tissue and iso-
intense signal on T1-weighted images. In addition, multiple
discrete, spherical hyper-intense lesions, separated by a
low signal intensity fibrous network, were noted on T2-
weighted images. Some of these lesions showed central foci
of low signal intensity, forming the dot-in-circle sign (tar-
get sign) that indicates mycetoma grains (Figures 1B, 2, 3). Figure 4. Sagittal T1-weighted post-contrast image of eumycetoma in the
hand, showing an extensive lesion infiltrating the subcutaneous, muscle
The mycetoma grains appeared as a low-intensity signal at
and carpal bone planes; note enhanced granulomatous tissue (long arrow)
all pulse sequences and did not enhance on post-contrast with non-enhanced low-signal foci (fungal grains) and microabscesses
study (Figure 4). Skin sinuses and sinus tracts were seen in (arrow heads).
 M.E. EL Shamy et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 106 (2012) 738–742
with bone cavitation or destruction or both, were com-
monly seen in patients with eumycetoma. Thus MRI allows
a degree of differentiation between eumycetoma and
actinomycetoma, but cannot be used to make an accurate
distinction between the two conditions.
The MRI findings were grouped into three sets accord-
ing to the Mycetoma Skin, Muscle, Bone Grading System
(MSMBS):
• skin and subcutaneous plane findings, including fascial
plane obliteration, abscess formation, and sinus tract for-
mation with or without the presence of grains.
• muscle plane findings, namely muscle oedema, and for-
mation of microabscesses or macroabscesses or both.
• bone plane findings, including bone marrow oedema,
bone cavitation and bone destruction.
The incidences of these findings are shown in Table 1.
The MSMBS allows a patient’s mycetoma lesion to be clas-
sified as mild (1–3), moderate (4–7) or severe (8–10).
Of the patients in our study, four (9.5%) had mild disease,
20 (47.6%) had moderate disease and 18 patients (42.9%)
had severe disease. There was no statistically significant
correlation between the MRI findings and disease duration
(p=0.234) or mycetoma type (p=0.712). There was a sta-
tistically significant correlation between MRI findings and
lesion size (p<0.0).
4. Discussion
Although mycetoma is a chronic granulomatous disease
it has many features of a malignant neoplasm, includ-
ing massive local destruction, spread along fascial planes
and via lymphatic and blood vessels, and recurrence after
adequate treatment; hence a severity grading system is
essential for disease assessment.2,7 It also worth noting that
the apparent clinical features of mycetoma are not always
a reliable indicator of the extent and spread of the dis-
ease; some small lesions with few sinuses may have a deep
network of connecting tracts, through which the disease
has spread quite extensively.3,8,9 The proper management
of patients with mycetoma requires both identification of
the causative organism and determination of the extent
to which the disease has spread along the different tissue
planes.
In mycetoma, many imaging and diagnostic tools are
available; however, many of them are invasive and cannot
accurately determine how far the mycetoma has spread or
the extent of tissue involvement.10,11 A mycetoma lesion
has a characteristic appearance on ultrasound, which is
able to differentiate between eumycetoma and actino-
mycetoma, and between mycetoma and other conditions.
However, the size of lesions and the extent of spread along
different tissue planes, knowledge of which is important
in planning surgical incisions, cannot be accurately deter-
mined ultrasonically.11
X-ray examination is not very helpful in the manage-
ment of mycetoma patients. In the early stages of the
disease x-ray appearances are essentially normal, radiolog-
ical findings being evident only in advanced disease, so it
is not possible by this technique to determine accurately
741
the extent of tissue involvement. Furthermore, the radio-
logical differential diagnosis of mycetoma includes many
conditions such as osteogenic sarcoma, bone cysts and
osteomyelitis.4,10,12
A literature review revealed a few case reports that
had described MRI findings in mycetoma.13–15 However,
the present study is the first prospective study to describe
and grade mycetoma severity on the basis of MRI findings.
The findings described in this study are characteristic of
mycetoma. The dot-in-circle sign, described by Sarris and
colleagues, is a unique MRI sign for mycetoma.14 It is seen
as a tiny, hypointense focus within high-intensity spherical
lesions on T2-weighted, STIR (short T1 inversion recov-
ery), and T1-weighted fat-saturated gadolinium-enhanced
images. The sign represents mycetoma grains surrounded
by inflammatory granulomata. Czechowski and associates
have suggested that the dot-in-circle sign is attributable to
metabolic products within the grains,16 but further studies
are needed to confirm this.
It is not uncommon for histopathological sections taken
from mycetoma biopsies to reveal features of a chronic,
non-specific granulomatous inflammatory reaction, with
no grains; in these situations it is difficult to substanti-
ate the diagnosis of mycetoma. Grains may be few, and
scattered in small areas of the extensive tissue involved,
and therefore missing in many histopathological sections.
However, MRI can show the grains as conglomerated
hypointense foci scattered in the lesion, and that is diag-
nostic.
The study showed that non-invasive MRI imaging can
help in the early diagnosis of mycetoma, even in the
absence of sinuses and discharge. The dot-in-circle sign,
conglomerated foci of low signal intensity, or macro-
and microabscesses on a background of a hypointense
matrix are all diagnostic of mycetoma. MRI can differen-
tiate between eumycetoma and actinomycetoma, but the
distinction is not clear cut and this aspect needs further
refinement.
We found no correlation between MRI findings and dis-
ease duration, which can be explained by the nature of the
disease. Actinomycetoma usually spreads and affects vari-
ous tissues fairly quickly, as it is more inflammatory than
eumycetoma and has no surrounding capsule, whereas
eumycetoma is a more localised disease and commonly
well encapsulated.
CT scanning is used for the diagnosis of mycetoma,
but the technique is not specific and the differential diag-
nosis includes many other conditions; however, bone
involvement can be determined more accurately with
this modality. Bonifaz and colleagues showed that heli-
cal computed tomography, with its three-dimensional
reconstruction, can provide precise information on actino-
mycetoma invasion at the different tissue planes.17
5. Conclusion
MRI is recommended for the diagnosis of mycetoma
and to determine its severity and the extent of tissue
invasion. MRI is also helpful in planning the different
treatment modalities for mycetoma. The MSMB grading
system allows disease in different patients to be classified
742 M.E. EL Shamy et al. / Transactions of the Royal Society of Tropical Medicine and Hygiene 106 (2012) 738–742
and compared. Further studies are needed to determine to
what extent the grading system can be used to determine
a patient’s prognosis.
Authors’ contributions: All the authors contributed to:
the conception and design of the study; patients’ clini-
cal management; the analysis and interpretation of data;
drafting the article or revising it critically for intellectual
content; approving the final version.
Funding: None received.
Competing interests: None declared.
Ethical approval: The study was approved by the Ethical
Committee of Soba University Hospital, Khartoum.
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