The missing grains in Madura foot: imaging to the rescue


  • Gopinath V. P. K. Department of Dermatology, MES Medical College, Malappuram, Kerala, India
  • Ali Rishad C. M. Department of Dermatology, MES Medical College, Malappuram, Kerala, India
  • Farisa P. M. Department of Dermatology, MES Medical College, Malappuram, Kerala, India



Mycetoma, Atypical, Dot In Circle, Imaging


Mycetoma or Madura foot is a chronic localized granulomatous infection caused by varied species of fungi or actinomycetes clinically diagnosed by active discharging sinuses containing ‘grains’. In atypical presentations or patients unwilling for invasive investigations, imaging essentially plays a key role in diagnosis and helps to differentiate actinomycetoma from eumycetoma. Here we present such an atypical case of unilateral foot swelling without sinuses–cryptic mycetoma. This 69 year old male from Kerala had a swelling over the left foot following trauma initially painless. An x-ray taken showed normal underlying bones with mild soft tissue swelling. To evaluate further USG was taken which showed fine hyperechoiec foci settled at the bottom of cavities highly suggestive of mycetoma. For confirmation USG guided biopsy was taken but was inconclusive. As patient was not willing for repeat biopsy, we advised non invasive MRI that revealed classical ‘Dot In Circle’ sign specific for mycetoma. The distinction that makes the case stand out is its absence of classical picture of discharging sinuses and the fact that imaging rather than histopathology helped confirm the diagnosis in mycetoma.

Author Biographies

Gopinath V. P. K., Department of Dermatology, MES Medical College, Malappuram, Kerala, India


Department of Dermatology

Ali Rishad C. M., Department of Dermatology, MES Medical College, Malappuram, Kerala, India

Junior resident

Department of Dermatology

Farisa P. M., Department of Dermatology, MES Medical College, Malappuram, Kerala, India

Junior Resident

Department of Dermatology


Bravo FG, Arenas R, Sigall DA. Actinomycosis Nocardiosis and Actinomycetoma. In: Wolff K, editor. Fitzpatrick’s dermatology in general medicine, 7th ed. New York: The McGraw-Hill Companies; 2008: 1784-1786.

Relhan V, Mahajan K, Agrawal P, Garg VK. Mycetoma: An Update. Indian J Dermatol. 2017;62:332-40.

Ahmed AA, Sande WVD, Fahal AH. Mycetoma Laboratory Diagnosis: Review Article. PlosNegl Trop Dis. 2017;11(8):E0005638.

Kumar MMS, Kumar VS, Kumar P, Anandan V. Mycetoma- A resurgence. IP Indian J Clin Exp Dermatol. 2018;4:44-7.

Laohawiriyakamol T, Tanutit P, Kanjanapradit K, Hongsakul K, Ehara S. The “dot-in-circle” sign in musculoskeletal mycetoma on magnetic resonance imaging and ultrasonography. Springer Plus. 2014;3:671.

Welsh O, Al-Abdely HM, Salinas-Carmona MC, Fahal AH. Mycetoma Medical Therapy. PLoS Negl Trop Dis. 2014;8(10):e3218.

Reis CMS, Reis-Filho EGM. Mycetomas: an epidemiological, etiological, clinical, laboratory and therapeutic review. An Bras Dermatol. 2018;93:8-18.

Hay RJ, Mahgoub ES, Leon G, Al-Sogair S, Welsh O. Mycetoma. J Med Vet Mycol. 1992;30:41-9.

McGinnis, Michael R. Mycetoma. Dermatologic Clin. 1996;14:97-104

Van de Sande WWJ. Global Burden of Human Mycetoma: A Systematic Review and Meta-analysis. PLoS Negl Trop Dis. 2013;7(11):1-11.

Gooptu S, Ali I, Singh G, Mishra RN. Mycetoma foot. J Family Community Med. 2013;20:136-8.

Lynch JB. Mycetoma in the Sudan: Hunterian Lecture delivered at the Royal College of Surgeons of England on 12th March 1964. Ann R Coll Surg Eng. 1964;35:319-40.

Fahal AH, Hassan MA. Mycetoma. Br J Surg. 1992;79:1138-41.

Tilak R, Singh S, Garg A, Bassi J, Tilak V, Gulati A. A case of Actinomycotic mycetoma involving the right foot. J Infect Dev Ctries. 2009;3:71-3.

Iffat H, Abid K. Mycetoma Revisited. N Dermatol Online. 2011;2:147-50.

Palestine RF, Rogers RS. Diagnosis and treatment of mycetoma. J Am Acad Dermatol. 1982;6:107-11.

Saha S, Dhar A, Karak AK. Mycetoma Sans Sinuses. Indian J Dermatol Venereol Leprol. 2006;72:143-4.

Jain V, Makwana GE, Bahri N, Mathur MK. The “Dot in Circle” Sign on MRI in Maduramycosis: A Characteristic Finding. J Clin Imaging Sci. 2012;2:66.

Sen A, Pillay RS. Case Report: Dot-In-Circle Sign – An MRI And USG Sign For “Madura Foot”. Indian J Radiol Imaging. 2011;21:264-6.

Abdalla OA, Ahmed. Unexpected High Prevalence of Secondary Bacterial Infection in Patients with Mycetoma. J Clin Microbiol. 1998;36:850–1.

Fahal A, Mahgoub ES, Hassan AME, Abdel-Rahman ME. Mycetoma in the Sudan: An Update from the Mycetoma Research Centre, University of Khartoum, Sudan. Plos Negl Trop Dis. 2015;9(3):e0003679.

Develoux M, Dieng MT, Kane A, .Management of mycetoma in West-Africa. Bull Soc Path Exo. 2003;96(5):376-82.

Abd El-Bagi ME1, Fahal AH. Mycetoma revisited. Incidence of various radiographic signs. Saudi Med J. 2009;30(4):529-33.

Fahal AH, Sheik HE, Homeida MM, Arabi YE, Mahgoub ES. Ultrasonographic Imaging Of Mycetoma. Br J Surg. 1997;84:1120-2.

Cherian RS, Betty M, Manipadam MT, Cherian VM, Poonnoose PM, Oommen AT, Cherian RA. The “Dot-In-Circle” Sign- A Characteristic MRI Finding In Mycetoma Foot: A Report Of Three Cases. Br J Radiol. 2009;82:662-5.

Czechowski J. MR And Other Imaging Methods In The Investigation Of Mycetomas. Acta Radiologica. 2014;42:24-6.

Damle DK, Mahajan PM, Pradhan SN, Belgaumkar VA, Gosavi AP, Tolat SN, Gokhale NR, Mhaske CB. Modified Welsh regimen: a promising therapy for actinomycetoma. J Drugs Dermatol. 2008;7(9):853-6.

Palit, Aparna, Ragunatha S, Inamadar AC. “Actinomycetoma: dramatic response to modified two-step regimen”. Int J Dermatol. 2011;50:446-9.