Treatment of Mycetoma
Treatment depends critically on whether the mycetoma is actinomycetoma (bacterial) or eumycetoma (fungal), as these require completely different therapeutic approaches and have markedly different prognoses.
Actinomycetoma (Bacterial)
First-line treatment combines trimethoprim-sulfamethoxazole (co-trimoxazole 80/400 to 160/800 mg per day) with amikacin 15 mg/kg body weight per day. 1
- Trimethoprim-sulfamethoxazole alone or combined with diamino-diphenyl-sulfone is the treatment of choice for actinomycetoma 2
- Amikacin should be used for severe cases, those unresponsive to initial treatment, or when there is danger of dissemination to adjacent organs 2
- Surgery is seldom required for actinomycetoma 2
- Treatment duration is prolonged, typically requiring courses of antibiotics over extended periods 3
- Actinomycetoma has a more favorable prognosis than eumycetoma and responds better to medical therapy 4, 3
Eumycetoma (Fungal)
Itraconazole 200 mg twice daily is the gold standard for eumycetoma treatment. 1
- Itraconazole at 200 mg twice daily is considered the most successful treatment option and represents the current standard of care 1
- Ketoconazole 400 mg/day was previously the medical treatment of choice for eumycetoma caused by Madurella mycetomatis, but has been discontinued by the FDA 1, 2
- A combination of medical treatment and surgery is advised for eumycetoma 2
- Small eumycetomas are more easily surgically removed 2
- Fluconazole has been unsuccessful in treating eumycetoma 2
- Amphotericin B has shown variable therapeutic response ranging from good to poor 2
Critical Treatment Considerations
Eumycetoma has no truly acceptable curative treatment at present; antifungals are unable to eradicate the fungus, require prolonged administration (often years), and are expensive. 3
- Treatment must be long-term for both forms, with eumycetoma requiring particularly extended therapy 4, 3
- Amputations and recurrences are common in patients with eumycetoma 3
- Early diagnosis and treatment are crucial, as mycetoma is preventable and treatable especially in early stages 4
- Left untreated, mycetoma may involve underlying bone and muscle, leading to permanent disability 4
Diagnostic Imperative
Accurate identification of the causative organism is absolutely crucial before initiating treatment, as actinomycetoma and eumycetoma require fundamentally different therapeutic approaches. 5
- Diagnosis should include grain examination, microscopy, culture, and imaging (radiography, ultrasonography, MRI) 4
- Molecular methods such as PCR and molecular sequencing are increasingly important for rapid and correct diagnosis, especially in culture-negative cases 4
- Grain color, size, consistency, and histopathology contribute to organism identification 2
Holistic Management Approach
Treatment may require a comprehensive strategy comprising antimicrobials, surgery, and rehabilitation, particularly given the high morbidity and socioeconomic burden of this disease 4. The prognosis is significantly better for actinomycetoma than eumycetoma, with medical therapy alone often sufficient for bacterial cases, while fungal cases typically require combined medical-surgical management with higher rates of treatment failure 4, 3.