bonifaz a, ibarra g, saúl a, carrasco e. dermatology & micology department general hospital of...
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Bonifaz A, Ibarra G, Saúl A, Bonifaz A, Ibarra G, Saúl A, Carrasco E.Carrasco E.
Dermatology & Micology Dermatology & Micology Department Department
General Hospital of General Hospital of MexicoMexico
Hospital Infantil de Hospital Infantil de MexicoMexico
MYCETOMA IN CHILDREN
Title
MYCETOMA IN CHILDRENMYCETOMA IN CHILDRENIntroduction
Chronic infection Based on its etiology: eumycetoma
(true fungae) actinomycetoma (filamentous actinomycetes)
Clinically characterized by swelling, sinuses and alteration of affected region
Mycetoma are uncommon in children. Only few reports*
* Aceves Ortega R. Deep mycosis in children. Mod Probl Paediatr 1975;17: 228-241.
Welsh O. Mycetoma in children. Mod Probl Paediatr 1975; 17:248-253.
Introduction
Occurs in well-defined geographic areas. Between the tropics
Actinomycetoma is more frequent in subtropical areas (Mexico, Venezuela)
Eumycetoma: predominates in Africa and India
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Background
Frequency: Mexican multi-center study that included
2,105 cases.* 78 cases were under 15 years: 3.7% 11 cases were under 10 years: 0.5% In our study: 15/334: 4.5%
*López-Martínez R, Méndez-Tovar LJ, Lavalle P, Welsh O, Saúl A, Macotela-Ruiz E. Epidemiología del
micetoma en México: estudio de 2105 casos. Gac Med Mex 1992; 128: 477-481.
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Background
Factors to development mycetoma:
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Factors Patient’s condition
Hormonal
Inoculum
Background
Mycetoma is an occupational disease…
Traumas Farm labors More frequent in
boys, maybe help more in farm works
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Ecology
Sub-tropical area: actinomycetoma
Nocardia spp Tropical-Senegalese
climate: Eumycetoma.
Madurella mycetomatis y Pseudoallescheria boydii
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Clinical
Two clinical features:Classical form: swelling, sinuses and
alteration of affected region Milder presentation (mini-
mycetoma): 1 or 2 sinuses (no-swelling). Clinical diagnosis is more difficult
Seldom involvement of bones and viscera
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Six (1)
Eigth (1)
Nine (2)
Ten (2)
Eleven (1)
Twelve (3)
Thirteen (2)
Fourtheen (1)
Fiftheen (2)
Mean 11.2 years
Range: 6-15 years
AgeMYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Boys Girls
12 boys 80%
3 girls 20%
Gender MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Foot-leg
Shoulder
Foot
Back
Hand
Clinical
locationMYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Farm work 12
Downsyndrome 1
House work 1
None 1
Predisposing factors MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
A 10 year old boy Evolution: 2 years Dermatosis
localized to the right leg. Pruritus
Direct exam: Nocardia granules
N. brasiliensis
A 12 year old girl Evolution: 1 year Dermatosis
localized to the left shoulder. Pruritus
Direct exam: Nocardia granules
N. brasiliensis
A 15 years old boy Evolution: 3 years Localized to the left
foot. Pain Direct exam:
eumycetic black granules
M. mycetomatis
A 11 years old girl Evolution: 8 months Dermatosis
localized to the left arm. Pruritus
Direct exam: Nocardia granules
N. brasiliensis
A 10 years old boy Evolution: 4 months Dermatosis
localized to the left leg. Pruritus & pain
Direct exam: Nocardia granules
N. asteroides
A 14 years old boy Evolution: 1 year Milking worker Dermatosis
localized to the hand right.
Biopsy: A. madurae granules
Actinomadura madurae
A 15 years old boy Evolution: 6 months Dermatosis
localized in torax. Pain
Direct exam: Nocardia granules
N. brasiliensis
A 6 years old girl Evolution: 2 years Dermatosis
localized to the left shoulder. Pruritus
Direct exam: Nocardia granules
N. brasiliensis
A 17 year old boy Evolution: 4 years Dermatosis localized
to the torax. Pruritus & pain
Direct exam: Nocardia granules
N. brasiliensis
A 13 years old boy Evolution: 4 years Dermatosis
localized to the torax. Pain
Direct exam: Nocardia granules
No culture
Lab
Diagnosis
Direct examination (KOH, lugol & ISS) Grains or granules Culture (Sabouraud, PDA, etc.) Identifying microorganisms Biopsy
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
N. brasiliensis80%
N. asteroides7%
M.mycetomatis13%
MYCETOMA IN CHILDRENMYCETOMA IN CHILDRENEtiology
Actinomycetoma: TMP-SMX + DDS Amikacin Amoxicilin/clavulanateEumycetoma: Griseofulvin Ketoconazole, itraconazole
MYCETOMA IN CHILDRENMYCETOMA IN CHILDRENTreatment
Cure
Improvement
Shortest: 8 months
Longest: 2.5 years
Mean: 1.3 years
MYCETOMA IN CHILDRENMYCETOMA IN CHILDRENTreatmentresponse
TMS-SMX + DDS
TMS-SMX + DDS
TMS-SMX + DDS
Summary IComment: Successful treatment depends on 3
conditions: the etiologic agent, the extent and depth of the mycetoma, and the patient condition
Good prognosis
- 14 years-old
- Healthy
N. brasiliensis
Summary IIComment: Successful treatment depends on 3
conditions: the etiologic agent, the extent and depth of the mycetoma, and the patient condition
Bad prognosis
- Deficient GI absorption
- Osteolysis
M. mycetomatis
Conclusions
Mycetomas are exceptional in children In Mexico actinomycetomas are more
frequent than eumycetomas Clinical and diagnosis is simple Treatment response is better for
actinomycetomas than eumycetomas
• Bonifaz A, Saúl A, Ibarra G, Rosales A, Araiza J, Méndez-Tovar LJ. Micetoma en niños y adolescentes. Monogr Dermatol 2006; 19: 17-23
• Bonifaz A, Ibarra G, Saúl A, Paredes-Solis V, Carrasco-Gerard E, Fierro-Arias L. Mycetoma in children. Experience with 15 cases. Pediatr Infect Dis J 2007; 26: 50-52
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN
Final
Thank you very much for your attention
MYCETOMA IN CHILDRENMYCETOMA IN CHILDREN