Mycetoma is a descriptive term to describe a number of bacterial and fungal infections with a similar clinical appearance. The etiologic agents are typically saprophytic organisms found in soil or plant debris that gain entry to skin and subcutaneous tissue through minor trauma. The original description in the Madura region of India and the most common clinical involvement of the foot are the origins of the common clinical name, "Madura foot." The same process may occur in the hand and, less commonly, other locations on the body. The infection has broad geographic distribution with an increased incidence in tropical and subtropical areas (2).

The clinical presentation is that of a slowly progressive, fistulizing swelling of a localized area. Pain is variable and often less than one might anticipate from visual inspection. As the disease progresses, bony destruction occurs. Characteristic granules may be seen to exit from the fistulae and are of a variety of colors depending on the organisms (17).

Mycetomas are caused by a variety of bacteria and fungi. Bacteria include, predominantly, members of the genus Actinomadura and Nocardia and are referred to as actinomycetomas. Frequent fungal pathogens include the genera of Madurella and Scedosporium (1,17,18,19).

The diagnosis is based on the clinical appearance and the presence of granules in the fistulae. The diagnosis may be supported by the radiographic appearance of bony destruction. A definitive diagnosis requires the microbi-ologic isolation of the offending organisms, which are best obtained from surgical biopsy. The differential diagnosis includes botryomycosis, tuberculosis, coccidioidomycosis, and other chronic invasive infections (17,18).

Medical treatment is dependent on the isolation of the pathogen and an understanding of its sensitivity. Surgery has a limited or no role in treatment, outside of assisting in diagnosis (18,19).

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