International Journal of Clinical & Medical Images

Case Report: A 32 year-old woman was referred to our outpatient clinic with a diagnosis of chronic swelling on the whole right forearm. Her past history included an accidental injury to the right wrist as he was working in a farm in Sudan 10 years before. At the beginning of the illness, she developed a single firm, painless nodule on the wrist which increased in size over months and on the surface of which vesicles gradually appeared. Then, the vesicles burst and multiple sinus tracts were formed which began discharging fluid containing small granules. The sinus tracts healed and re-occurred intermittently, discharging a sero-purulent yellowish-gray fluid. Within 6 years, there was extensive involvement of the volar and the dorsal surface of the forearm. Most of her wrist movements were restricted with deformations. She has been treated surgically and medically for the past five years in different centers in Sudan. Physical examinations revealed an extensively swollen right forearm with multiple discharging sinuses and foul smelling (Figure 1). Laboratory investigations revealed a normal leukocyte count, anemia (Hb 8.9 g/dl), a high ESR (120 mm/h) and high C-reactive protein (CRP: 13.3). Radiologic examination of the forearm showed osteolytic lesions, periosteal reaction and bone destruction in the forearm bones with massive soft tissue swelling. Fine needle aspiration confirmed the diagnosis of mycetoma. The patient underwent above elobow amputation. In advanced and neglected cases of mycetoma, amputation seems to be inevitable [1,2]. Therefore, we encourage clinicians to maintain a high index of suspicion in cases of chronic, granulomatous infection of the upper limb. We recommend a multidisciplinary approach to the chronic granulomatous infection of the upper extremity.