Case presentation
A 40 year old female farmer from Sudan referred to our orthopedic
oncology clinic at Ibrahim Malik Teaching Hospital –Sudan, complaining
of chronic right distal forearm pain, swelling and numbness for two
years, it started with small painless lump that over period of time
increased in size gradually, recently her quality of life and functional
status had been massively affected due to increasing pain intensity,
increase symptoms anguish and constant decrease in range of motion at
the wrist joint. Patient were ill but not pale, no loss of weight
neither constitutional symptoms were noted, vital signs were within
normal range. No Sinuses were noted throughout the course of
presentation. Conventional xray show right distal radius mixed lytic and
sclerotic bone lesion with sunburst periosteal reaction and soft tissue
swelling [fig1] . Initially and with inadequate assessment, she was
suspected with osteosarcoma distal radius, thus she was referred. No
advance imaging requested, or biopsies were taken. Since then the
deterioration in her general condition had been growing steadily.
Painful activity of daily living agonized the patient, swelling and
limitation of movement on the affected side had been worsening
dramatically. Furthermore she ended by using daily pain killer for long
time. On clinical examination there was obvious right distal forearm
swelling and tenderness mainly at the radial and dorsal side of the
forearm, the mass was irregular in shape, hard in consistency measured
about 7*3 cm, with mild temperatures asymmetry compared with adjacent
skin, no sinuses were identified lymphatic streaks. Hematological
investigations were unremarkable, X-ray revealed the same findings and
MRI of right wrist show right distal forearm swelling (enhancement)
incasing distal neurovascular bundle , pre-tumor edema , no skip
lesions[fig2-3]. CT chest & chest X-ray were normal, no evidence of
metastases. At this point the decision was to take core biopsy under
general anasthesia. Histopathology analysis reports multiple grains of
streptomyces somaliensis surrounded by granulasion tissues with gaint
cell granuloma, the features of actinomycetoma consistent with
streptomyces somaliensis[fig4] . Second surgery i.e. wide local
excision and fixation was done and second biopsy were taken, confirming
the diagnose.
After two months from operation the patient’s condition improved and
referred to mycetoma center in Soba hospital for medications [fig5]
.