Eumycetoma by Madurella mycetomatis with 30 years of\nevolution: therapeutic challenge
We describe a case of a white 49-year-old male patient, from the state of Ceará, Brazil,\nwho presented asymptomatic cutaneous lesions, in the thighs and gluteus, for 30 years,\nwith progressive swelling of the affected areas. The patient reported the onset of the\nlesion after a local trauma, caused by sliding down a waterfall of his home state.\nPhysical examination revealed multiple erythematous nodules, both palpable and visible,\nassociated with fistulas with exudation of serosanguineous material and black grains,\nlocated on the anterior, lateral and posterior face of the proximal third of the thigh\nand in the infragluteal regions (). Edema\nand local erythema were present, with no palpable lymphadenopathy. The patient was in\ngood general condition, with no systemic signs or symptoms.\nThe histopathological study of one of the lesions, with hematoxylin-eosin and Grocott's\nmethenamine silver stains, showed amorphous brownish grain-like material with\neosinophilic edges and septal hyphae at its core (). The culture of the grain, in Sabouraud Agar, grew Madurella myce\ntomatis. Radiological evaluation by computed tomography showed a\nconsiderable amount of nodular thickening at the skin and subcutaneous levels, with\nunaffected muscle and bone.\nThe patient was treated with fluconazole 200mg/day and itraconazole 200mg/day for four\nyears, undergoing five semiannual surgical procedures aimed at excision of the\nsubcutaneous nodules. Medical discharge was achieved two months after the last surgery,\nwith no clinical or radiological evidence of residual lesions.\nEighth year of follow-up, a new asymptomatic, well delimited skin-colored nodule, of\napproximately 2 cm in seize, without a fis- tula was observed in the right infragluteal\nregion (). After excisional biopsy of the\nlesion, with observation of black grains and Madurella mycetomatis\ngrowth in culture, the diagnosis of eumycetoma was confirmed (). After new image tests showed no remaining\nlesions, the patient was kept under follow-up, without antifungal chemotherapy.