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By: Joseph St. Geme, MD

  • Chair, Department of Pediatrics, Professor of Pediatrics and Microbiology, Perelman School of Medicine at the University of Pennsylvania
  • Physician-in-Chief, Leonard and Madlyn Abramson Endowed Chair in Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania


Aspergillus may also be an etiologic organism and is thought to spasms vs seizures 500mg robaxin sale originate from the middle ear or mastoid muscle relaxant cyclobenzaprine high purchase robaxin 500mg with amex. Elderly diabetics are thought to spasms below rib cage buy discount robaxin 500mg on line be particularly susceptible because of the microangiopathic changes that blunt an already attenuated immune response muscle spasms youtube discount 500mg robaxin mastercard. In children, the clinical course of the disease progresses more rapidly, often manifesting with pseudomonal bacteremia. In contrast to that seen in adults, the tympanic membrane and middle ear are often involved. Cranial neuropathies occur in more advanced presentations of disease, and the facial nerve is the most frequently affected cranial nerve. Further progression may lead to sigmoid sinus thrombosis, meningitis, sepsis, and death. Cultures and sensitivity should be obtained to aid in selecting appropriate antibiotics. Control of hyperglycemia and immunosuppression is necessary to maximize treatment. The use of hyperbaric oxygen has been described in cases refractory to antibiotics, with variable results. In an effort to prevent skull base osteomyelitis, all diabetic and immunocompromised patients must be followed up closely and treated aggressively if they present with symptoms suggestive of external otitis. Aminoglycosides (eg, tobramycin) and antipseudomonal -lactam antibiotics, including piperacillin, ticarcillin, or ceftazidime, may be used. Sagittal image of a bone scan in a patient with skull base osteomyelitis revealing focal enhancement of the skull base. Atopic skin lesions have been shown to have higher levels of Th2 T-lymphocytes, which produce inflammatory mediators such as interleukin 4, 5, and 10. Opacification or "oil spots" of the nails, as well as pitting and subungual hyperkeratosis, are also suggestive of this disease. Psoriatic lesions may present over areas of trauma, an entity known as Koebner phenomenon. There is variability in skin lesions ranging from erythematous patches to weeping plaques. Secondary infections with S aureus, herpes simplex virus, vaccinia, and molluscum contagiosum may occur. Atopic dermatitis is characterized by the absence of specific laboratory and histologic markers. Elevated IgE and eosinophilia may be present yet are not specific for the diagnosis. For the ears and face, treatment includes low-dose topical nonfluorinated corticosteroids such as alclometasone, mometasone, desonide, clocortolone, hydrocortisone valerate, and butyrate creams and topical calcipotriene. Differential Diagnosis the differential diagnosis includes seborrheic dermatitis and psoriatic dermatitis. Antihistamines and lubricants may be used for the treatment of accompanying pruritus. Moisturizers and mild soaps are preferred to minimize exposure to potential allergens found in many cosmetic products. Though often self-limited, the disease may recur spontaneously and can become chronic. Eighteen percent of patients with psoriasis have some involvement of the external ear, which may be secondary to extension from the scalp. Males and females are equally affected, with the onset of disease typically occurring in adolescence. Pathogenesis the cause of seborrheic dermatitis remains unknown, but an association with Pityrosporum ovale and Malassezia furfur has led to the approval of ketoconazole shampoo for treatment. Clinical Findings Seborrheic dermatitis is characterized by greasy scales overlying erythematous and often pruritic plaques. The distribution is frequently not limited to the ears and often involves the scalp, forehead, eyebrows, glabella, and nasolabial folds. Pathogenesis the cause of psoriasis is unknown, yet there is a strong genetic component. Intermediate- or high-dose glucocorticosteroids (eg, betamethasone or fluocinonide) are needed for more severe presentations and to alleviate pruritus. Fluorinated topical glucocorticoids may worsen lesions when used on the face or ear. Seborrheic dermatitis can often become chronic with periods of exacerbation and remission. Superinfection should be treated with warm compresses, topical antibiotics, and selective use of oral antibiotics. Pathogenesis First branchial cleft anomalies occur as a result of anomalous fusion of the first and second branchial arches, with incomplete obliteration of the first branchial cleft. Clinical Findings Patients may present with a cyst or tract along the anterior border of the sternocleidomastoid muscle. One may also see a corresponding tract at the junction of the bony and cartilaginous ear canal. The patient may have a history of recurrent infection and drainage from the ear or neck. Eruption may occur secondary to instrumentation, foreign objects-including jewelry, ear plugs, and hearing aids-and other objects used to scratch pruritic lesions. The tract may be intimately involved with the facial nerve, which is at risk during excision. This is in contrast to irritant-mediated contact dermatitis, which usually manifests earlier. Clinical Findings Allergic contact dermatitis is characterized by an indurated, erythematous, pruritic, and poorly demarcated process. This is in contrast to irritant dermatitis, which often presents with well-defined areas of exposure. Treatment the avoidance of exposure to irritants and allergens and high-dose topical glucocorticoids are the mainstays of therapy. Pathogenesis Freezing temperatures lead to both direct cellular injury as well as vascular compromise. Prolonged exposure to cold temperatures can lead to vasoconstriction, cold-mediated dehydration, endothelial injury, thrombosis, and ischemia of auricular tissue. In the early stage, this process may be reversible, but over time, it leads to tissue necrosis. Ultimately, as the ear thaws, pain, erythema, and subcutaneous bullae secondary to extravasated extracellular fluid or blood may develop. Full-thickness, subdermal, and deep partial-thickness burns of the auricle heal with scarring and contracture and may be complicated by suppurative chondritis. These burns should be treated with both topical (usually silver based) and systemic cartilage penetrating antibiotics. Secondary reconstruction is usually performed at approximately 1 year after injury. Aloe vera has antithromboxane properties and, together with ibuprofen, may aid in reestablishing circulation.

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Bilateral three-quarter views are useful to spasms near temple robaxin 500 mg overnight delivery analyze the alar cartilages and the tiplobule complex muscle relaxant erowid discount 500 mg robaxin. Bilateral lateral views allow for the evaluation of tip projection and rotation spasms ms order 500mg robaxin visa, the length of the nose spasms hamstring purchase 500 mg robaxin visa, and the symmetry of the nostrils and columella. In addition, any disruption of the silhouette of the nose, such as dorsal humps or the absence of supraor infratip breaks, can be evaluated. Finally, a basal view allows for an evaluation of columellar length, tip projection, base width, nostril notching, deviations, and asymmetries. Regardless of choice, local anesthesia should be administered to improve surgical hemostasis, to aid in patient analgesia, and to aid in atraumatic dissection by infiltration into favorable and appropriate tissue planes. Overzealous injection should be avoided because this leads to a distortion of anatomy. Regional field blocks of the supratrochlear, infraorbital, and nasopalatine nerves also can improve patient analgesia (in the case of local anesthesia with intravenous sedation) and hemostasis. Photographic Documentation Photographs are essential for the evaluation, diagnosis, and surgical planning of every patient. Four milliliters of 4% cocaine (160 mg) is below the toxic dose of 3 mg/kg in most adult patients. Next, the lateral nasal walls should be injected via an intercartilaginous approach, staying close to the nasal bones and injecting as the needle is withdrawn. The needle is then inserted through the vestibule toward the alar-facial groove to inject the angular artery. An injection is also placed at the base of the columella toward the nasal spine to control the columellar branch of the facial artery. The tip is finally injected via the vestibule, anterior to the alar cartilage and into the dome, with placement confirmed by blanching. The lateral crural excision is performed after a retrograde dissection from the intercartilaginous incision. The major benefits of the closed approaches are less dissection leading to less edema and faster healing, and the absence of a transcolumellar incision. The endonasal approach is used by many surgeons primarily when nasal tip morphology is normal. External Approach the external or open approach involves bilateral marginal incisions that are connected in the midline by a transcolumellar skin incision, usually in the shape of an inverted "V. It also allows for better binocular visualization, both for teaching and studying deformed anatomy. In addition, the open approach allows for a more precise control of bleeding by electrocautery and a more precise correction of deformities. The disadvantage is the skin incision on the columella and the degloving of the nose, which may be associated with more postoperative edema. The cartilage-delivery method is an example of a closed approach that combines multiple endonasal incisions. In this approach, intercartilaginous incisions are combined with marginal incisions to allow for either externalization or delivery of the lateral crura. This allows for an enhanced visualization of the cartilage, an improved ability to manipulate the domes under direct vision, and better postoperative symmetry. Other examples of closed approaches to the tip include the transcartilaginous approach and the retrograde approach. In the transcartilaginous approach, a predetermined amount of lateral Tip-Lobule Complex Alteration and molding of the alar cartilage must be done with precision to avoid visible deformities. Thick skin does not contract well to an underprojected cartilage framework and worsens tip definition. Rather than deprojecting tip cartilages or weakening them by aggressive cephalic trims, definition can be improved only by increasing alar cartilage projection so the underlying framework pushes up into the thick overlying skin envelope. Frequently, tip grafts are required for optimal tip definition in these patients, although other techniques that increase projection can also be effective. The conjoined medial crura form the medial "leg" and each lateral crus forms the other two "legs. For example, if the conjoined medial crura lose support or are shortened, the tip rotates caudally. If both lateral crura are symmetrically shortened, either posteriorly or in mid-span, cephalic rotation occurs. It is important to note that the shape of a weakened alar cartilage may also be modified by the contraction of scar tissue during the healing process or by the formation of bossae or knuckles over time. Overresection must be avoided to maintain stable alar cartilages, which allows for an accurate prediction of the surgical outcome. Made from septal cartilage, it adds stability to the medial crura, allows for enhanced tip definition and projection, and prevents tip ptosis. The strut is placed in a pocket between the medial crura and extends just beyond the medial crura footplate. It should not rest on the nasal spine because this may cause clicking if it moves over the bone. When the caudal septum is long, care should be taken to shorten it before strut placement to prevent excess columellar show results. In addition, tip grafts or dome-binding sutures may be used to improve tip projection and definition. It is caused by convex, long, and poorly defined lateral crura that are rounded because of an obtuse angle at the dome. To address this, cephalic trim is used to reduce the curvature of the lateral crura and to create a flat profile. At least 7 mm of remaining crura are needed to ensure sufficient stability and strength. The excision of a triangle of cartilage just lateral to the domes is then used to reduce rounding from the obtuse angle. Staying lateral to the apex of the dome maintains the defining point of an unchanged tip, and the resection of a superior-based triangle allows cephalic rotation and narrowing of the dome. Care should be taken that such excision does not result in increased alar retraction. Suture reconstitution of the lateral crura is important because it maintains the strength of the nasal skeleton. Nasal Valves the most common cause of acquired incompetence of the internal or external nasal valves is rhinoplasty. Some obstruction can be dynamic, with underlying weakness of the internal or external nasal valve evident only with inspiration. A spreader graft, placed between the dorsal septum and the upper lateral cartilage, is used to widen the angle and improve problems with the internal nasal valve, improving both static and dynamic obstruction at this level. External valve incompetence is caused by excessive resection and weakening of the lateral crura of the alar cartilage, either congenital or acquired from excessive resection of the lateral crura. Repair is most commonly performed by placement of either a batten graft (overlying the lateral crus or stabilizing a deficient area) or an alar strut graft (underlying the lateral crus and straightening it) to strengthen the cartilage and prevent collapse. Repair is most commonly by placement of either a lateral graft that spans the crura or a batten graft to strengthen the cartilage and prevent collapse. Alar retraction is most often caused by poor support of the alar margin resulting from aggressive alar cartilage excisions. It may be corrected by placing a graft in a pocket along the alar rim (rim graft), by repositioning a cephalically oriented lateral crus more caudally, or, in severe cases, by using a composite ear cartilageskin graft to increase vestibular length. It is thick over the nasion, thinnest at the rhinion, and thick again in the supratip area.

However spasms under breastbone purchase 500 mg robaxin, on a site basis muscle relaxant neck pain order robaxin 500 mg, 33% of the sites had 1 to muscle relaxant yellow house generic robaxin 500 mg with visa 3 mm of coronal soft tissue displacement and 29% of sites had 1 to spasms just under rib cage order 500 mg robaxin visa 4 mm of recession between 6 weeks and 6 months. No further changes in attachment loss occurred after the initial 6 weeks of healing, nor did probing depths change. The study emphasized the need to delay margin placement in areas of esthetic concern up to 6 months following crown lengthening surgery. Temporary Restorations Waerhaug (1980) created cavity preparations which extended subgingivally in monkeys and dogs. The preparations were subsequently filled with self-curing acrylic resin, zinc oxide and eugenol, or gutta percha. Histological observation 13 to 283 days after restoration placement indicated initial plaque formation at the tooth-restoration interface which spread over the restoration and eventually over the tooth surface apically. Prognostic considerations included patient age, systemic condition, patient behavior, clinical form of the disease, disease rate of progression, tooth anatomy, malocclusion, and habits. The strategic value of individual teeth was evaluated by comparing anterior and posterior and left and right segments. Molars and canines were assigned a value of 3; second molars, second premolars and centrals, 2; and first premolars and laterals, 1. These values were decreased by 1 if the tooth had 50 to 80% bone loss, Class I furcation invasions, or mobility. With > 50% bone loss and more involved furca, the strategic value was reduced by 2. Each segment had to score > 3 for a fixed prosthesis to have a favorable prognosis. According to the authors, esthetic considerations for osseous resective surgery include increased crown length, with the lip frame, lip line, and anterior overbite requiring consideration. Treatment plans should include initial preparation; caries control and defective restoration repair; pathological tooth migration correction; provisional stabilization; endodontics; surgical periodontics, postsurgical endodontics; clinical and radiographic reevaluation at 12 weeks; final restorative phase and final periodontic, endodontic, and prosthetic evaluations prior to final cementation. The authors felt that the final prosthesis should be divided into segments of < 6 units, occlusal forces should be directed along the long axis of the teeth, and initial cementation should be temporary (3 months) followed by re-evaluation. If soft tissue form and surface characteristics are deemed unacceptable, corrections should precede fabrication of the restoration (Hunt, 1980). Circumstances permitting, pontics should be placed over keratinized tissue rather than alveolar mucosa. Ridge augmentation may be accomplished by internal connective tissue grafts, free soft tissue onlay-autografts, or ridge transposition. When the ridge is covered by excessive amounts of soft tissue, ridge reduction can be accomplished by gingivoplasty or internal soft tissue wedge reduction. Ridge reduction surgery may be required to increase the vertical clearance between the residual ridge and opposing occlusion. Surgery (vestibuloplasty-free soft tissue autograft) may also be required in areas where shallow vestibules complicate oral hygiene or predispose to adverse interactions between the soft tissue and pontics associated with fixed or removable prostheses. Allen (1988) described mucogingival treatment techniques to enhance anterior tooth esthetics. He recommended having the gingival margins on incisors peak slightly distal to the midline of the teeth. These recommendations should take into account whether full coverage restorations are to be utilized with root exposure avoided if restorations are not planned. Crown Contour Eissmann (1971) discussed physiologic design criteria for effective restorative function, comfort, and hygiene. Protective contours were described as convex (prominences) while stimulatory contours were concave (sluiceways, embrasures). Protective convexities relate to clinical crown length, decreasing in prominence as the distance from the occlusal table to the free gingival margin increases. Physiologic tooth contouring is directed at minimi/ing plaque retention by exposing the largest possible area of the clinical crown to cleansing by food flow patterns, musculature, and mechanical oral hygiene devices. Overcontouring causes plaque accumulation and inflammation and is potentially more detrimental to the periodontium than undercontouring (Youdelis et al. Supragingival and subgingival contours should have a flat emergence profile or angle (Kay, 1985). The character and dimension of the gingival tissues are the primary variables affecting subgingival contours. Thin friable tissue is less tolerant of subgingival restorative invasion and is more susceptible to shrinkage and marginal recession. Becker and Kaldahl (1981) emphasized access for oral hygiene and suggested guidelines for crown contours. The guidelines included: 1) "Flat," not "fat" buccal and lingual contours: the normal bucco-lingual contour of teeth without caries is flat with a bucco-lingual bulge, usually < 0. Ridges with visible inflammation were termed "involved," while those without visible signs of inflammation were considered "uninvolved. When tissue was excised from the residual ridge, a transient reduction of 1 mm in tissue height occurred; however, the original ridge height returned within 1 year regardless of whether a pontic was placed. When polished ridge-lap pontics were placed, 90% produced visible inflammation of mucosa regardless of the material (gold, porcelain, acrylic); furthermore, daily flossing under the pontic aggravated the problem. The author concluded that pontic design was more important than the material used in the pontic construction. The ideal design should have pinpoint, pressure-free contact on the facial slope of the ridge, and all surfaces should be convex, smooth, and highly polished or glazed. This pontic design offers the most favorable balance between comfort, support, and hygiene, but may appear unesthetic anteriorly. Becker and Kaldahl (1981) recommend the modified ridge-lap design posteriorly and the ridge-lap facing design anteriorly. Overdentures Johnson and Sivers (1987) discussed periodontal considerations for overdentures. Selection of abutment teeth is based on prosthodontic and periodontal considerations, including bone support and architecture, width of attached gingiva, tooth mobility, root anatomy, and tooth position. A greater width of attached gingiva may be necessary when the tissue is subjected to mechanical stresses and plaque accumulation accompanying the prosthesis. Mobility patterns are often improved by reducing the crown to root ratio during abutment preparation. Molars and furcated maxillary premolars make poor abutment choices due to concavities, grooves, and possible furcation invasions. Periodontal surgery may be necessary to reduce pockets, augment attached gingiva (keratinized tissue), and increase vestibular depth where indicated. Hygiene adjuncts using end-tufted brushes and daily application of fluoride are beneficial. Overdenture abutments generally have an increase in gingivitis, and patients with poor oral hygiene and sporadic professional maintenance frequently experience increased caries and attachment loss at overdenture abutments. Periodontic-Prosthodontic-Restorative Interactions Longitudinal Evaluation of Periodontal-Prosthetic Treatment Nyman and Lindhe (1979) longitudinally evaluated combined periodontal and prosthetic treatment of patients with advanced periodontal disease. Participants included 251 patients with dentitions devoid of 50% or more of the periodontal support who had received periodontal surgery and prosthetic rehabilitation. Initial clinical and radiographic evaluations were completed following treatment and annually for 5 to 8 years. No additional attachment loss occurred and bone levels were maintained for all types of fixed partial dentures, including cantilevers. This study suggests that periodontal tissues surrounding fixed partial denture abutments do not react differently from tissues around non-abutment teeth. It should be noted that supragingival margins and excellent oral hygiene were consistently observed in the study population. Silness (1980) reviewed selected investigations of periodontal health adjacent to fixed prostheses, examining the concepts that had emerged, and relating these to actual clinical practices. The review included 342 individuals with 357 bridges that had been in place up to 6 years. Group 1 consisted of 197 subjects who had received periodontal treatment and were given oral hygiene instructions prior to prosthodontic treatment.


  • Hemophagocytic reticulosis
  • M?ller Barth Menger syndrome
  • Retinitis pigmentosa-deafness
  • Ciliary dyskinesia-bronchiectasis
  • Multicentric osteolysis nephropathy
  • Fistulous vegetative verrucous hydradenoma

Physical examination revealed extensive lesions in scaly plaques situated at different sites on the face spasms just below rib cage robaxin 500mg on-line, arm infantile spasms 2012 buy genuine robaxin, and leg spasms pelvic area generic robaxin 500mg otc. Direct potassium hydroxide examination of biopsies of the lesions showed numerous pigmented muscle relaxant and anti inflammatory order robaxin 500 mg amex, bilaterally dividing, rounded, sclerotic cells (Medlar bodies), thus confirming the clinical diagnosis of chromoblastomycosis. Cultures of the biopsies grew a darkly pigmented mold that was identified on the basis of characteristic conidiation as Rhinocladiella aquaspersa. The lesions improved with ketoconazole therapy, with decreasing pruritic symptoms. Furthermore, this case is unusual in that the lesions were dispersed over three different anatomic regions. Morphology the fungi that cause chromoblastomycosis are all dematiaceous (naturally pigmented) molds but are morphologically diverse, and most are capable of producing several different forms when grown in culture. Although the basic form of these organisms is a pigmented septate mold, the different mechanisms of sporulation produced in culture makes specific identification difficult. It is characterized by the development of slowgrowing verrucous nodules or plaques (Figure 63-5). Chromoblastomycosis is most commonly seen in the tropics, where the warm, moist environment, coupled with the lack of protective footwear and clothing, predisposes individuals to direct inoculation with infected soil or organic matter. Muriform cells divide by internal septation and appear as cells with vertical and horizontal lines within the same or different planes (see Figure 63-6). The fungal cells may be free within the tissue but most often are contained within macrophages or giant cells. Treatment Treatment with specific antifungal therapy is often ineffective because of the advanced stage of infection upon presentation. In an effort to improve the response to treatment, attempts are often made to shrink larger lesions with local heat or cryotherapy before administering antifungal agents. Because of the risk of recurrences developing within the scar, surgery is not indicated. Squamous cell carcinomas may develop in long-standing lesions, and those with atypical areas or fleshy outgrowths should be biopsied to rule out this complication. Epidemiology Chromoblastomycosis generally affects individuals working in rural areas of the tropics. Most infections have been in men and involve legs and arms, likely the result of occupational exposure. Local climatic factors may influence the distribution of different infections and different etiologic agents. For example, in Madagascar, infections caused by Fonsecaea pedrosoi are seen in areas of high rainfall (200 to 300 cm annually), whereas in the same island, infections caused by Cladophialophora carrionii occur in areas of low rainfall (50 to 60 cm annually). A mycetoma is defined clinically as a localized, chronic, granulomatous, infectious process involving cutaneous and subcutaneous tissues. It is characterized by the formation of multiple granulomas and abscesses that contain large aggregates of fungal hyphae known as granules or grains. These grains contain cells that have marked modifications of internal and external structure, ranging from reduplications of the cell wall to the formation of a hard cement-like extracellular matrix. The abscesses drain externally through the skin, often with extrusion of granules. The process may be quite extensive and deforming, with destruction of muscle, fascia, and bone. The etiologic agents of eumycotic mycetoma encompass a wide range of fungi, including Phaeoacremonium, Curvularia, Fusarium, Madurella, Mediacopsis, Biatrophia, Trematosphaeria, Exophiala, Falciformispora, and Scedosporium/ Pseudallescheria species (see Table 63-1). Clinical Syndromes Chromoblastomycosis tends to be chronic, pruritic, progressive, indolent, and resistant to treatment. In most instances, patients do not present until the infection is well established. There are different morphologic forms of the disease, ranging from verrucous lesions to flat plaques. Established infections appear as multiple large, warty, "cauliflower-like" growths that are usually clustered within the same region (see Figure 63-5). Large lesions are hyperkeratotic, and the limb is grossly distorted because of fibrosis and secondary lymphedema (see Figure 63-5). Secondary bacterial infection may also occur and contribute to regional lymphadenitis, lymph stasis, and eventual elephantiasis. Splendore-Hoeppli material often interdigitates among the mycelial elements at the periphery of the granule. Culture is usually necessary for definitive identification of the fungus (or actinomycete) involved. Laboratory Diagnosis the clinical presentation (see Figure 63-5), histopathologic findings of chestnut-brown muriform cells (see Figure 63-6), and isolation in culture of one of the causal fungi (see Table 63-1) confirm the diagnosis. Biopsy specimens stained with hematoxylin and eosin (H&E) (see Chapter 60) will also show the organism present in the epidermis or in microabscesses containing macrophages and giant cells. The inflammatory reaction is both suppurative and granulomatous, with dermal fibrosis and pseudoepitheliomatous hyperplasia. B, Compact dematiaceous hyphae and chlamydoconidia embedded in Epidemiology Mycetomas are primarily seen in tropical areas with low rainfall. Eumycotic mycetomas are more frequent in Africa and the Indian subcontinent but also may be seen in Brazil, Venezuela, and the Middle East. All patients are infected from sources in nature via traumatic percutaneous implantation of the etiologic agent into exposed parts of the body. The foot and hand are most common, but back, shoulders, and chest-wall infections are also seen. The fungi that cause eumycotic mycetomas differ from country to country, and the agents that are common in one region are rarely reported from others. Most organisms will grow on standard mycologic medium; however, inclusion of an antibiotic such as penicillin may be useful to inhibit contaminating bacteria, which may overgrow the fungus. Response of the various etiologic agents to amphotericin B, ketoconazole, or itraconazole is variable and often poor, although such therapy may slow the course of infection. Promising treatment responses have recently been reported for terbinafine, voriconazole, and posaconazole. Local excision is usually ineffective or not possible, and amputation is the only definitive treatment. For all these reasons, it is imperative to differentiate eumycotic mycetoma from actinomycotic mycetoma. Clinical Syndromes Similar to chromoblastomycosis, patients with eumycotic mycetoma most commonly present with long-standing infection. The earliest lesion is a small, painless, subcutaneous nodule or plaque that increases slowly but progressively in size. As the mycetoma develops, the affected area gradually enlarges and becomes disfigured as a result of chronic inflammation and fibrosis. With time, sinus tracts appear on the skin surface and drain serosanguineous fluid that often contains grossly visible granules. The infection commonly breaches tissue planes and destroys muscle and bone locally. Hematogenous or lymphatic spread from a primary focus to distant sites or viscera is extremely rare. Laboratory Diagnosis the key to the diagnosis of eumycotic mycetoma is the demonstration of grains or granules. Grains may be grossly visible in draining sinus tracts or may be expressed onto a glass slide. The hyphae are usually clearly visible, as is the presence or absence of pigmentation. Both of these fungi cause a chronic subcutaneous form of mucormycosis that occurs sporadically as a result of traumatic implantation of the fungus present in plant debris in tropical environments. This form of subcutaneous entomophthoromycosis occurs mainly in children (80% < age 20), with a male/female ratio of 3; 1.

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