 |
|
 |
An infectious disease of the feet (and occasionally the upper extremity), characterized by chronicity, tumefaction, and multiple sinus formation, that progresses unless excised or amputated; death occurs occasionally in neglected cases, usually from complicating bacterial disease.
Etiology, Incidence, and Pathology
About half the cases are caused by Nocardia spp, the remainder by some 20 different fungi and bacteria. The disease is most prevalent in the tropics and occasionally in the southern USA; it is usually contracted by men between ages 21 and 40. Pathologically, tumefaction and draining sinuses are visible grossly; hence tissue reaction is predominantly suppurative, but invariably granulomas are also present microscopically.
Symptoms and Signs
The first lesion may be a papule, a deep-seated fixed nodule, a vesicle with an indurated base, or an abscess that ruptures and produces a fistula. Early lesions are granulomatous but later are surrounded by a dense fibrous capsule and intersected by fibrous trabeculae. Lesions are usually nontender unless secondary infection is present. The disease progresses slowly; 6 to 8 papules or abscesses may form in succession and then disappear. Months or years may pass before muscles, tendons, fascia, and bone are destroyed. The patient is able to walk until deformity or muscle wasting intervenes.
In advanced cases, the foot characteristically appears as a grotesque, swollen, club-shaped mass of cystlike areas with multiple draining and intercommunicating sinuses and fistulas that discharge an "oily" or serosanguineous fluid.
Diagnosis
Diagnosis is made from the clinical course, appearance, and demonstration of colored granules in the exudate. These characteristic fungus granules measure 0.5 to 2 mm, are irregularly shaped, and vary in color.
The etiology of the disease (and of the granules) is established only by crushing and culturing the granules. Multiple bacteria and fungi are commonly found in the same foot and same drainage. Systemic symptoms are rare.
Prognosis and Treatment
The course may be prolonged for > 10 yr; the patient eventually may die from sepsis or intercurrent disease, unless the infecting organism is sensitive to an antimicrobial agent.
Actinomyces infections should be treated with penicillin or a tetracycline (ACTINOMYCOSIS) and those caused by Nocardia spp, with a sulfonamide. If the fungus is sensitive, amphotericin B or ketoconazole may be helpful. Amputation of the limb may be required to prevent secondary bacterial infection and fatal outcome.
|
 |
