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CASE PRESENTATION
What is the diagnosis??
04/09/2015
Dr. J. Jagoda – Consultant Rheumatologist/DGH GampahaDr A. P. J. Cooray – Senior Registrar-Rheumatology/RRH Ragama
Mr. P : 37 year old driver - 2003•Mild discomfort and a lump in the
anterior aspect of the knee ▫No other joint swelling ▫No fever▫No rash▫No recent history of an illness▫No trauma
Visits a Consultant Physician•Some blood tests were done
▫?ESR/FBC – were said to be normal•Reassured and given painkillers•Lump regresses leaving behind an
indurated area of skin and another two appear at different locations▫Ignored by the patient▫Not painful▫No discharge▫No systemic illness▫Heal with scarring
2005 – He goes to the Surgeon
•Lump reappears at a different location▫Discharges grainy material▫Previous scars also start discharging▫FBC – Thrombocytosis, ESR 39mm▫X-Ray: Soft tissue swelling with periosteal
reaction▫US scan : 4.5/2.0 cm cystic lesion
superficial to the Tibia. Impression is that of a chronic abscess
Superficial nodule is excised - 2005•Histopathology report ; fibro connective
tissue shows foci of eosonophillic crystalline material surrounded by neutrophills and pallisades of histiocytes. The stoma shows sheets of inflammatory cells
Conclusion; The features are compatible with goutgout
##Uric acid – 2.6mg/dl
Severe knee pain with joint swelling - 2009•Fluid aspirated out from KJ
▫Full report and culture sent▫Mantoux test negative▫Chest X ray – nothing to suggest TB
Pain relief is given – feels well till 2013 ( Still has discharging nodules)•Tries ayurvedic treatment
▫Severe pain in KJ with swelling and fever▫Goes to a Consultant Rheumatologist
WBC 11.6 * Neutrophill predominent, Platelets 691000
ESR 130mm/CRP 96mg/dl Aspirated out MRI done Arthroscopic synovial biopsy arranged
MRI report
Pigmented villonodular synovitis•A benign proliferative disorder of the
synovium•Clinical pattern
▫Isolated tenosynovitis (Tenosynovial giant cell tumour)
▫Diffused form▫Localized form
MRI – characteristic appearance: Low signal intensity lesion in T1/T2 sequences
Histopathology – synovial proliferation with foam cells & haemosiderin laden giant cells
Antibiotics for 2 weeks and pain relief•ROM is now diminished •Multiple scar marks on his left knee•New subcutaneous nodules keep
appearing•But no other joint involvement•He is feeling well i.e no fever, no night
sweats, no loss of weight
Back to our patient - 2014
•Multiple discharging nodules with stiffness of the knee▫ESR – 52mm▫Normal FBC▫FNAC of nodule : suppurative inflammation▫Synovial biopsy repeated▫Trial of ATT considered
What can it be?
•Bone and joint TB•Gout•Rheumatoid arthritis•Tumour•Some other rare cause
BIOPSY REPORT 2014
Mycetoma
•Chronic granulomatous subcutaneous infection
•Aetiology▫Actinomycetes – A.Pelletieri, A.Madurae,
Nocardia sps▫Fungi – P.boydii, M.Mycetomatosis
Clinical phases
•Painless subcutaneous swelling▫Indurated area
•Subcutaneous nodule
•Spread to contiguous tissue▫Sinus tracts – sulphur granules
Diagnosis
•Imaging▫Radiography/CT▫US scan▫MRI
•Laboratory diagnosis▫Histopathology▫Culture
Features1.Cortical
thickening2.Periosteal
reaction3.Lytic
lesions
Features1. Dot in circle sign
Histopathology
•FNAC or wedge biopsy•Synovial biopsy
▫Gram stain/Geimsa stain
Identifying the causative organismActinomycetoma Eumycetoma
• Filamentous bacteria• Gram positive• 01 micrometer or less• Periphery is basophillic
and the center is eosonophillic
• Large grains
• True fungai with hyphae and many chlamydophores
• Gram negative• 2-4 micrometers• Large grain is 5mm or
more
ManagementActinomycetoma Eumycetoma
• Co-trimaxozole• Dapsone and
Streptomycin• Rifampicin• Gentamycin• Penicillin
• Itraconazole
Do we finally have a diagnosis
•? Is it eumycetoma or actinomycetoma
Thank you
•Acknowledgements▫Dr C.S.P Sosai – Consultant
Histopathologist▫Dr P. Rathnayake – Consultant
Histopathologist▫Dr M. Kothalawela – Consultant
Microbiologist
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