Advanced Eumycetoma of the Right Foot Resulting in Below-Knee Amputation in Somalia: A Case Report.

Introduction: Mycetoma is a chronic, progressively destructive neglected tropical disease that presents with localised swelling, multiple sinus tracts and a discharge containing grains, and that may extend into deep tissue and bone. Somalia lies within the recognised mycetoma belt, but the national burden is poorly documented, and few patients reach specialist care early enough for the limb to be saved. Case Presentation: A 33-year-old man from Qoryooley District, Lower Shabelle, Somalia, presented with a seven-year history of progressive swelling of the right foot. Examination showed massive tumefaction and multiple discharging sinuses containing black grains. Magnetic resonance imaging demonstrated extensive soft-tissue destruction, sinus tracts, tendon involvement and osteomyelitis of several tarsal and metatarsal bones. Histopathological examination confirmed eumycetoma. Specialised fungal culture and molecular testing were not available at the institution, so the causative species could not be identified. Because the extent of soft-tissue destruction and multi-bone involvement left no viable limb-sparing option, a right below-knee amputation was performed, followed by oral itraconazole planned for twelve months. At three months the stump had healed with no clinical evidence of recurrence, and the patient continued antifungal treatment and rehabilitation. Conclusion: Delayed diagnosis of eumycetoma can cost the patient a limb. Magnetic resonance imaging determined management here by mapping the extent of disease and showing that limb-sparing surgery was no longer feasible. Earlier referral, and better access to imaging, mycological diagnosis and antifungal treatment, would spare other patients in Somalia the same outcome.