Bonifaz A, Ibarra G, Saúl A, Carrasco E. Dermatology & Micology Department General Hospital of Mexico Hospital Infantil de Mexico MYCETOMA IN CHILDREN.

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