Late presentation of the majority of patients is commonly seen in Sudanese patients, the justification of this delay are multifactorial, with reasons including the painless clinical nature of the lesion, poor health centers in remote areas, patients’ low socioeconomic status and lack of health education.
As mentioned above the treatment of mycetoma depends mainly on the etiological agent, site of infection, and extent of the disease . Until recently in Sudan, the only available treatment for mycetoma was amputation or multiple surgical excisions, as no therapeutic consensus has been reached. Actinomycetoma is usually treated with medication only. For eumycetoma, a combination of medical treatment in the form of anti-fungal and various surgical excisions is the gold standard .
According to the New Radiographic Classification of Bone Involvement in Pedal mycetoma by Mohamed E. Abd El Bagi, our patient radiographs shows soft tissue involvement, cortical erosion, and central cavitation of solitary bone (calcaneus) its classified as class 3 . Cortical erosion and central cavitation are commonly seen in patients with Eumycetoma Osteomyelitis, revision of X-ray by orthopedic surgeon or radiologist is always recommended in such cases to minimize the rate of the misdiagnosis.
Eumycetoma causative agents is difficult to ascertain. Hence, assessment should include full pathological analysis of the affect area such fine needle aspiration cytology and histopathology to build solid diagnosis. Fine-needle aspirations under aseptic conditions is required to identify the causative agent of mycetoma and the tissue reaction against it. Wide local excision or deep incisional biopsy taken under local anesthesia are usually inadequate specimens, avoidance of such sample are now recommended as a Tru-Cut needle biopsy in use and above all immunohistochemistry is needed .
The postoperative recurrence rate varies from 25–50%, the Predictors of Post-operative mycetoma Recurrence depends on age, duration, site of involvement and no previous history of mycetoma surgical operation considers the lowest risk of recurrence . Therefore, our patient was classified accordingly as low risk of recurrence.
Unfortunately since eumycetoma has a poor response to medical therapy, surgical approaches are all that is available. Many Sudanese patients undergo many operations with several regimens of ketoconazole and itraconazole to enable better response to good outcome. Surgical options for mycetoma treatment range from a wide local surgical excision to repetitive debridement excisions to amputation of the affected part. Adequate anesthesia, a bloodless field, wide local excision with adequate safety margins are mandatory for good prognosis and surgical outcome . Surgical intervention usually associated with high rate of morbidity and disability among mycetoma patients in Sudan. In order to reduce rate of complication we do need to raise the awareness among the patients and families about the importance of early medical advice especially in endemic areas.
Post-operative wound care, physiotherapy and adherence of antifungal agent are mandatory for better surgical outcomes and to avoid the joint stiffness and reduce deformities and disabilities. Peri-operative and post-operative antibiotics with good dressing techniques are needed to improve the overall surgical outcome.