Actinomycetoma: dramatic response to modified two-step regimen.

Mycetoma is a chronic granulomatous infection of the subcutaneous tissue caused by fungi or fungus-like bacteria. The infection eventually spreads to bone resulting in significant morbidity. Rarely, viscera may be involved through contiguous spread. It is common in tropical countries like India, though disease is worldwide in distribution. A 22-year-old male patient, a farmer by occupation, presented with multiple discharging sinuses over the left chest wall, shoulder, upper arm, and adjacent neck of eight months duration. A diagnosis of actinomycetoma was made based on clinical and histopathological features as culture was negative for both fungus and bacteria. The patient was treated with a modified two-step regimen. It consisted of an intensive phase with intravenous gentamicin 80 mg 12th hourly and cotrimoxazole 320/1600 mg twice daily orally for four weeks. This was followed by a maintenance phase with oral cotrimoxazole and doxycycline 100 mg twice daily. Patient showed excellent response with healing of all sinuses after two months of therapy. Involvement of covered parts of the body such as chest wall and shoulders is common in actinomycetoma compared to eumycetoma. Early institution of long-term combination therapy with antimicrobials results in excellent outcome.