PMC3518950_01
(a) Gross view of left leg anteromedial swelling sparing the knee, distal leg, ankle, and foot; (b) Closer view of the swelling showing the pouting sinuses.
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fig1
Hospital with a left leg anteromedial swelling associated with multiple sinuses discharging yellowish granules which had developed over the previous 4 years (Figures 1(a) and 1(b)).
Lateral X-ray of the left tibia-fibula showing cortical lytic defects with no periosteal reaction (''moth-eaten" appearance).
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fig2
Radiographs revealed tibial superficial cortical lytic defects without periosteal reaction (Figure 2).
(a) Slide showing several clusters of mycetoma organisms surrounded by reactive zone of leucocytes (granulomas) x10, H&E stain. (b) Closer look at a mycetoma granuloma showing the clusters of the organisms centrally and the surrounding leucocytes x20, H&E stain.
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fig3
An incisional biopsy revealed both actinomycetoma and eumycetoma with abscesses (Figures 3(a) and 3(b)).
(a) shows the good take of the skin graft and gastrocsoleus flaps; the sinuses have not recurred. (b) Lateral X-ray of the left tibia-fibula showing the resolution of the lytic defects in the tibia.
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fig4
Pre- and postoperatively he was treated with itraconazole and ciprofloxacin initially for 2.5 months then itraconazole and penicillin V for 8 months, with complete resolution (Figures 4(a) and 4(b)).