Actinomycetoma - NEJM
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A 64-year-old man was referred for evaluation of a multinodular tumor of the left foot. Foot lesions had been present for 38 years, starting on the left heel and gradually spreading to involve the whole foot and ankle, with walking impairment. At the time that the patient was first seen, he was in a wheelchair. The patient sought medical care because of fatigue related to anemia of chronic disease (hemoglobin level, 9 g per deciliter). He did not report problems with his foot, being accustomed to this condition. Examination revealed soft-tissue swelling; multiple painless, sometimes ulcerated, weeping tumefactions and ipsilateral popliteal and inguinal lymphadenopathy (Panel A and Panel B show the dorsal and plantar surfaces of the foot). Magnetic resonance imaging revealed osteomyelitis of the tarsal bones. The suspected diagnosis was a mycetoma, although Kaposi's sarcoma and epithelioma cuniculatum (verrucous carcinoma) were also considered. Pathological analysis of a punch-biopsy specimen with Giemsa staining revealed an inflammatory infiltrate surrounding granules with peripheral “clubs,” identified as actinobacteria. A culture of the specimens did not grow any organism. Amikacin (for 10 days) and trimethoprim-sulfamethoxazole were given. After 1 month, the patient was discharged home and was able to walk with crutches...

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