MYCETOMA INTERNATIONAL

MYCETOMA INTERNATIONAL
CONFERENCE
CONFERENCE
Monterrey, Mexico
Monterrey, Mexico
24
24
th
th
-26
-26
th
th
. May 2007
. May 2007
Elsheikh Mahgoub
Elsheikh Mahgoub
Faculty of Medicine
,University of
Khartoum,udan.

THERAPY OF MYCETOMA
THERAPY OF MYCETOMA


Mycetoma is a chronic,
localised slowly
progressive disease,
involving cutaneous,
subcutaneous tissue
and ultimately bone.



It is characterised by
It is characterised by
tumefaction, destructive
tumefaction, destructive
granuloma, deformity and
granuloma, deformity and
discharging sinuses with
discharging sinuses with
intercommunicating
intercommunicating
channels which exude pus
channels which exude pus
with granules of varying
with granules of varying
colour and size
colour and size

It is 52 years since
Professor onzalez !
"choa from your country
published his wor# on the
treatment of mycetoma
due to Nocardia brasiliensis
with Diamino-diphenyl
sulphone(DDS)and $%
years since the publication
of Professor Pedro &avalle.

'e published on successful
treatment of mycetoma
caused by Actinomadura
madurae, A.pelletierii,
Streptomyces somaliensis
and Nocardia brasiliensis
with Sulphamethoxazole
plus Trimethoprim (5
years ago.

&ater on in %)*+ we
&ater on in %)*+ we
published on the
published on the
treatment of %$$ cases
treatment of %$$ cases
of
of
actinomycetoma
actinomycetoma

using ,"M-I./0I".
using ,"M-I./0I".
0123/P4 of
0123/P4 of
Streptomycin and
Streptomycin and
cotrimoxazole
cotrimoxazole
or
or
streptomycin and DDS.
streptomycin and DDS.


In %)5$, together, with
In %)5$, together, with
Professor 6amia umaa,
Professor 6amia umaa,
we reported on the first
we reported on the first
successful treatment of
successful treatment of
2umycetoma due to
2umycetoma due to
Madurella
Madurella
mycetomatis
mycetomatis
by
by
ketoconazole
ketoconazole



"liverio 'elch and his
"liverio 'elch and his
colleagues 27 years ago,
colleagues 27 years ago,
in %)5*, reported on the
in %)5*, reported on the
use of
use of
Amikacin
Amikacin
alone and
alone and
in combination with
in combination with
Trimethoprim-
Trimethoprim-
sulphamethoxazole
sulphamethoxazole
in the
in the
treatment of
treatment of
actinomycetoma caused
actinomycetoma caused
by
by
N.brasiliensis.
N.brasiliensis.



/hmed 8ahal had a trial
/hmed 8ahal had a trial
with
Itraconazole
Itraconazole
to
to
treat patients with
treat patients with
eumycetoma caused by
eumycetoma caused by
Madurella mycetomatis
!"ata not yet #u$lished%.



/t present a trial is going
/t present a trial is going
on at the Mycetoma ,entre
on at the Mycetoma ,entre
in 9hartoum where
in 9hartoum where
patients with mycetomata
patients with mycetomata
due to
due to
A.madurae
A.madurae
,&#elletierii
,&#elletierii
and
and
S.somaliensis
S.somaliensis
are being
are being
treated with
treated with
amikacin
amikacin
.
.


Preliminary results are
Preliminary results are
impressive
impressive

TOPICAL APPROACH
TOPICAL APPROACH
2lfadil got his M: in 277$ by
wor#ing on the seeds of a
6udanese herb ;Lipdium
sativum) growing along the
'hite .ile.0he seeds of this
plant are ground and
emulsified in yogurt and
applied daily as a dressing to
the mycetoma even if the
lesion is closed.


Photo 19


0he latest report is that
of -onifaz et al Fe$ruary
2007 who reported on
successful treatment of
/ctinomycetoma due to
Nocardia spp. 'ith
Amoxyclav 87!"#


In a recent electronic
article on Mycetoma in
eMedicine, <anuary
277*,-asillio et al have
narrated all drugs used
in medical treatment of
mycetoma,their
dosage,mode of action
and side effects.


"liverio 'elch and
6alinas=,armona in
8ebruary 277* in the
same web site
published a
comprehensive article
updating treatment of
both actinomycetoma
and eumycetoma.


'e are conducting an
experiment to test in
vitro 6ensitivity of ()
strains of M. mycetomatis
a*ainst $lucona%ole,
&tracona%ole, 'etocona%ole
and (oricona%ole.



Antifungal Concn.
0
2
4
6
8
10
12
14
16
1/1000 500 250 125 62.5 31.2 15.6 7.8 3.9 1.9 0.97 0.8 0.2
!
o

o
f

"
t
#
a
i
n
$
Flucanarale Itraconozole etocuraz!e



Ketocona+ole



,tracona+ole

M.Mycetomatis a*ainst
-oricona+ole


"ur results show that
'etocona%ole is still the
most potent followed by
voricona%ole, &tracona%ole
and least by
$luccona%ole.


'ith this array of drugs
'ith this array of drugs
what approach or
what approach or
strategy should we
strategy should we
advise for 0herapy or
advise for 0herapy or
treatment of
treatment of
M4,20M/>>
M4,20M/>>

Questions to e ans!ered "irst#

Site o) mycetoma* ;Is 6urgery

Possible?

Actinomycetoma or Eumycetoma >

;:rugs :ifferent?

Any +revious mycetoma

treatment* ,0ry :ifferent :rug-

Any previous surgery*

,3ecurrence-

.hat drug cost can he!she a))ord.

!8or 6ustaining 0rt%

Actinomycetoma
Actinomycetoma


All agents o) actinomycetoma
All agents o) actinomycetoma

start with
start with
Streptomycin
Streptomycin
%
%
gram per day intramuscular.
gram per day intramuscular.
plus 2 tablets
plus 2 tablets
cotrimoxazole
cotrimoxazole
twice daily for one
twice daily for one
month.:o not disturb
month.:o not disturb
successful treatment. If
successful treatment. If
treatment fails shift to
treatment fails shift to
Amikacin
Amikacin
.
.

6.6omaliensis Mycetoma
pedis -efore 0reatment
with Streptomycin
cotrimoxazole.
/fter 0reatment

Trt"A#$%ac$n &Cotr$#o'azole


/efore
treatment
&fter 0reatment

Treatment
Treatment
If .o 3esponse, shift to
If .o 3esponse, shift to
6treptomycin :apsone
6treptomycin :apsone

1/e'are toxic effects to
1/e'are toxic effects to
/one marro'
/one marro'
Anaemia
Anaemia
Leucopenia. Supplement
Leucopenia. Supplement
trt /ith $e and $olic acid.
trt /ith $e and $olic acid.
2
2

Treatment
If no response, start
Amoxycillin$clavulanic
acid.

Trt. EUMYCETOMA


%etoconazole
%etoconazole
277 mg b.d.
277 mg b.d.
for ( wee#s. If response is
for ( wee#s. If response is
minimal try
minimal try
&oriconazole
&oriconazole

+mg@#g iv infused over 2
+mg@#g iv infused over 2
hrs and then
hrs and then
Itraconazole
Itraconazole
.
.


1 3hec4 5iver Function
1 3hec4 5iver Function
0ests $efore and monthly
0ests $efore and monthly
durin* trt.2
durin* trt.2

R%f%#%nc%$
R%f%#%nc%$



(.6on+ale+-7choa & ,(8)).9ffectiveness of"" in
(.6on+ale+-7choa & ,(8)).9ffectiveness of"" in
the treatment of 3hromo$lastomycosis and of
the treatment of 3hromo$lastomycosis and of
Mycetoma caused $y
Mycetoma caused $y
Nocardia brasiliensis,pp
Nocardia brasiliensis,pp
0#"10#72&n Sternberg34 and Ne/comer (5
0#"10#72&n Sternberg34 and Ne/comer (5
Eds3herapy o) $ungus 5iseases.Little,6ro/n 7
Eds3herapy o) $ungus 5iseases.Little,6ro/n 7
8o.,6oston.
8o.,6oston.


#.
#.
5avalle :,(866.3linica 0era#eutica de los
5avalle :,(866.3linica 0era#eutica de los
micetomas."ermatolo*y ,nternational,),((7-(20.
micetomas."ermatolo*y ,nternational,),((7-(20.


;.Mah*ou$ 9, (872.0reatment of
;.Mah*ou$ 9, (872.0reatment of
&ctinomycetoma 'ith ul#hamethoxa+ole #lus
&ctinomycetoma 'ith ul#hamethoxa+ole #lus
0rimetho#rim.<ournal of 0ro#ical medicine and
0rimetho#rim.<ournal of 0ro#ical medicine and
=y*iene ;;2-;;).
=y*iene ;;2-;;).


4.Mah*ou$ 9,(876.Medical Mana*ement of
4.Mah*ou$ 9,(876.Medical Mana*ement of
Mycetoma./ulletin of the >orld =ealth
Mycetoma./ulletin of the >orld =ealth
7r*ani+ation,)4,;0;-;((
7r*ani+ation,)4,;0;-;((. .

Re(erence)
Re(erence)


).Mah*ou$ 9 ? 6umaa
).Mah*ou$ 9 ? 6umaa
&,(8@4.Ketocona+ole in the
&,(8@4.Ketocona+ole in the
treatment of eumycetoma due to
treatment of eumycetoma due to
Madurella mycetomatis.
Madurella mycetomatis.
0ransactions
0ransactions
of the Aoyal ociety of 0ro#ical
of the Aoyal ociety of 0ro#ical
medicine and =y*iene 7@,;76-;68.
medicine and =y*iene 7@,;76-;68.


6.>elch 7,auceda 9,6on+ale+
6.>elch 7,auceda 9,6on+ale+
<,7cam#o <,(8@7.&mi4acin alone and
<,7cam#o <,(8@7.&mi4acin alone and
in com$ination 'ith trimetho#rim-
in com$ination 'ith trimetho#rim-
sul#hamethoxa+ole in the treatment
sul#hamethoxa+ole in the treatment
of actinomycotic mycetoma.<ournal
of actinomycotic mycetoma.<ournal
of the &merican &cademy of
of the &merican &cademy of
"ermatolo*y,(7,44;-44@.
"ermatolo*y,(7,44;-44@.

Re(erence)
Re(erence)
7.Fahal &=.Un#u$lished data.
7.Fahal &=.Un#u$lished data.
@.9lFadil &/.0reatment of 9umycetoma
@.9lFadil &/.0reatment of 9umycetoma
'ith a to#ical her$
'ith a to#ical her$
, Sativa
, Sativa
lipdium-.
lipdium-.
0hesis su$mitted for
0hesis su$mitted for
M",University of Khartoum.
M",University of Khartoum.
8./onifa+ &,2007.0reatment of
8./onifa+ &,2007.0reatment of
actinomycetoma due to
actinomycetoma due to
Nocardia spp
Nocardia spp
>ith amoxycillin-clavulanate./ritish
>ith amoxycillin-clavulanate./ritish
<ournal of "ermatolo*y,()6,;0@
<ournal of "ermatolo*y,()6,;0@
-;((.
-;((.

Re(erence)
Re(erence)


(0./asillio<,2007.Mycetoma.'''.em
(0./asillio<,2007.Mycetoma.'''.em
edicine.comBmedBto#ic;0.hto,(-().
edicine.comBmedBto#ic;0.hto,(-().


((.>elch 7,alinasC3armona
((.>elch 7,alinasC3armona
M3,2007.Mycetoma.'''.emedicine.
M3,2007.Mycetoma.'''.emedicine.
comBdermBto#ic2@0.htm(-(;.
comBdermBto#ic2@0.htm(-(;.