Madurella mycetomatis mycetoma treated successfully with oral voriconazole

Conflicts of interest: none declared Sir, Eumycetoma due to Madurella mycetomatis is a chronic, localized fungal disease endemic in some countries of Africa, the Middle East and Asia.1–3 Eumycetoma, and particularly chronic forms, require surgical debulking plus intensive antifungal treatment. This combined management is recommended by many authors but there is not yet consensus on treatment.1 Published results of antifungal therapy are often conflicting and therapeutic success with medical treatment alone has been very rarely reported.4, 5 Here, we report a case of M. mycetomatis mycetoma successfully treated with oral voriconazole alone. A 23‐year‐old man from Mali, who had been in France for 1 month, presented to our department in December 1998 with a tumefaction of the right sole. The lesion, diagnosed in Mali as a mycetoma in 1992, had been surgically removed in 1997, but recovery had been incomplete. Clinical examination revealed swelling of the right sole with emission of small black grains from sinuses (Fig. 1a). Direct examination of grains in potassium hydroxide plus black chlorazol E solution confirmed the presence of fungal hyphae. Four‐week cultures on Sabouraud's dextrose agar with antibiotics (Bio‐Rad, Marne la Coquette, France) at 27 °C showed dark‐brown colonies producing a diffusible pigment, identified as M. mycetomatis. Minimal inhibitory concentrations (MICs) of voriconazole could not be tested. Histological studies showed no grains. Magnetic resonance imaging showed extensive inflammatory lateral soft tissue involvement (5·5 cm long, 5 cm wide, 5 cm thick) with no signs of bone involvement (Fig. 2a). The patient received voriconazole 200 mg twice daily for 3 months, followed by 300 mg twice daily for 13 months. The lesion softened after 1 month of treatment, and a more marked improvement was noted 1 month after increasing the dose to 600 mg daily. Discharge of grains stopped after 3 months of treatment. After 4 months of treatment the lesion had shrunk to 5 cm long, 3 cm wide and 2·5 cm thick. After 6 months of treatment the right foot became identical to the left foot. No further lesions were noted clinically or radiologically (Fig. 2b) after 15 months of treatment. Voriconazole was well tolerated, and no adverse events occurred during the 16 months of treatment. The patient was still disease‐free 4 years after the end of treatment (Fig. 1b).