Mycetoma Pulmonary Secondaries from a Gluteal Eumycetoma: An Unusual Presentation

A 38-year-old teacher from theWhite Nile State in Sudan was referred to the Mycetoma Research Centre (MRC), University of Khartoum, Sudan, in 2009 with a massive gluteal eumycetoma. In 1996, he noted a small painless subcutaneous gluteal swelling, which gradually increased in size. Initially, a diagnosis of gluteal abscess was made, and he underwent drainage of a seropuruluent discharge at a district general hospital. This was followed by several wound debridements and regular dressing, but no diagnosis was established, and no medication was administered. By 2003, the lesion involved a wide area of the gluteal region and the upper part of the right thigh. A diagnosis of eumycetoma was established by grain culture and histopathological examination of the surgical biopsy, and he was started on oral ketoconazole at 200 mg a day; however, the treatment was discontinued after three months because of the drug’s adverse reactions. These reactions included skin hyperpigmentation, lip dryness and fissuring, gynecomastia, and hepatic function disturbances. He underwentmultiple wide local surgical excisions, but the disease continued its aggressive course, and in 2005 he underwent right hip disarticulation for disease control. The disease recurred soon afterward in the lower back. In 2009, he was started on oral Ketoconazole at 800 mg a day and underwent several wide local excisions. The disease relentlessly progressed to involve the lower posterior and anterior abdominal walls (Fig 1). He was hospitalized several times to eradicate the concomitant bacterial infections and control the stump phantom pains with appropriate antibiotics and opiates. By 2012, he developedmagnetic resonance imaging (MRI)-confirmed infiltration of the lumber and sacral vertebrae with intraspinal epidural extension (Fig 2), resulting in an inability to walk with his crutches, excruciating lower backache, difficulty in passing urine, and defecation. He was started on intravenous amphotericin B liposomal at 6 mg/kg on alternate days for four weeks with some improvement. This regime was followed by voriconazole at 800 mg a day for six months, but it had to be suspended because of abnormal hepatic function. Itraconazole at 800 mg a day was substituted. In June 2015, he was admitted with severe watery diarrhea, dyspnea, and a productive cough containing black grains for a hospital stay of one month (Fig 3). On examination, he was unwell, emaciated, and in pain. He had finger clubbing and generalized edema. Respiratory examination revealed reduced chest movements with bulging of the left intercostal spaces, a dull percussion note, and decreased air entry over the left lung.