Discussion and conclusion
Actinomycetoma Osteomyelitis radius is very rare condition to be
reported. Destructive bone pattern by mycetoma species, in situ grains
formation and Unequivocal distinction between actinomycetoma and various
manifestations of osteosarcoma either in painful event or numbness at
late stage are extremely rare findings to be seen, also the unique
periosteal reaction in form of sunburst ray appearance can also be the
source of significant diagnostic challenges, when it happens the risk of
limb loss by amputation will be very high. Initial Painless nature of
the lesion, low socioeconomic status and low level of education are the
reason drives Sudanese patients to present late.
As mentioned above the treatment of mycetoma predominantly depends on
the infective agent, site and extent of infection[12]. Until
recently in Sudan, amputation was the only available treatment for
mycetoma, as extremely high recurrence rate prevent optimum therapeutic
results to be reached.
Actinomycetoma (bacterial type) is usually treated with medications only
as it shows relative response to medical treatment in early stages. For
fungal type (eumycetoma), a combination of aggressive surgical and
medical treatment (anti-fungal agents) are the gold standard as drug
resistant prevent solely medical treatment [13].
Actinomycetoma infective agents are difficult to confirm. Hence,
accurate assessment should include proper clinical history and
examination, radiological evaluation by expert radiologist and
Orthopedist, pathological analysis of the affected area with a Tru-Cut
needle biopsy and immunohistochemistry to avoid problems of inadequate
specimens commonly associated with incisional biopsy [14]. Overall
outcome can be optimized significantly after precisely identification of
the causative organism and extended post treatment follow up.
Unfortunately due to the late presentation, aggressive features of bone
and surrounding structures Invasion found in our patient and fear of
high recurrence rate, surgical approaches in combination with
Medical treatment were decided. Many Sudanese patients undergo many
operations with several Prolonged medical regimens to enable adequate
response. Nevertheless, surgical options for mycetoma Treatment in Sudan
range from wide local excision to amputation of the affected limb,
correct wide local Excision and bloodless field by expertise during
surgery are paramount essential to excellence the Outcome [15].
The post treatment recurrence rate is high, range between 25-50%. Age,
duration, site and extent of Involvement and previous history of
mycetoma recurrence are predictors of overall outcome. Thereby, Surgical
operation considers the best treatment option to minimize the risk of
recurrence especially if Done properly as mentioned above[16].
Surgical intervention unfortunately associates with high rate of
morbidity and disability among Mycetoma patients in Sudan. Postoperative
extended follow up, physiotherapy of the nearby joints and Adherence to
antibiotics regimen regarding to the protocol are essential for better
clinical and functional Outcomes and to avoid the permanent
disabilities.(17)
In conclusion, actinomycetoma Osteomyelitis radius is rare condition.
Clinicians in endemic areas must Consider mycetoma osteomyelitis as a
differential diagnosis when they are dealing with vague atypical
Musculoskeletal destructive lesions. Multidisciplinary team and Triple
assessment including clinical, Radiological and histopathological
correlation are extremely important to prevent misdiagnosis, surgical
Treatment in combination with medical treatment followed by regular
clinical and radiological follow up Can be limb saving procedure in such
cases. Finally, treatment of mycetoma osteomyelitis cases is case By
case individually according to the predictors of post-operative
recurrence.(17)