Discussion and conclusion
Actinomycetoma Osteomyelitis radius is very rare condition to be reported. Destructive bone pattern by mycetoma species, in situ grains formation and Unequivocal distinction between actinomycetoma and various manifestations of osteosarcoma either in painful event or numbness at late stage are extremely rare findings to be seen, also the unique periosteal reaction in form of sunburst ray appearance can also be the source of significant diagnostic challenges, when it happens the risk of limb loss by amputation will be very high. Initial Painless nature of the lesion, low socioeconomic status and low level of education are the reason drives Sudanese patients to present late.
As mentioned above the treatment of mycetoma predominantly depends on the infective agent, site and extent of infection[12]. Until recently in Sudan, amputation was the only available treatment for mycetoma, as extremely high recurrence rate prevent optimum therapeutic results to be reached.
Actinomycetoma (bacterial type) is usually treated with medications only as it shows relative response to medical treatment in early stages. For fungal type (eumycetoma), a combination of aggressive surgical and medical treatment (anti-fungal agents) are the gold standard as drug resistant prevent solely medical treatment [13].
Actinomycetoma infective agents are difficult to confirm. Hence, accurate assessment should include proper clinical history and examination, radiological evaluation by expert radiologist and Orthopedist, pathological analysis of the affected area with a Tru-Cut needle biopsy and immunohistochemistry to avoid problems of inadequate specimens commonly associated with incisional biopsy [14]. Overall outcome can be optimized significantly after precisely identification of the causative organism and extended post treatment follow up.
Unfortunately due to the late presentation, aggressive features of bone and surrounding structures Invasion found in our patient and fear of high recurrence rate, surgical approaches in combination with
Medical treatment were decided. Many Sudanese patients undergo many operations with several Prolonged medical regimens to enable adequate response. Nevertheless, surgical options for mycetoma Treatment in Sudan range from wide local excision to amputation of the affected limb, correct wide local Excision and bloodless field by expertise during surgery are paramount essential to excellence the Outcome [15].
The post treatment recurrence rate is high, range between 25-50%. Age, duration, site and extent of Involvement and previous history of mycetoma recurrence are predictors of overall outcome. Thereby, Surgical operation considers the best treatment option to minimize the risk of recurrence especially if Done properly as mentioned above[16].
Surgical intervention unfortunately associates with high rate of morbidity and disability among Mycetoma patients in Sudan. Postoperative extended follow up, physiotherapy of the nearby joints and Adherence to antibiotics regimen regarding to the protocol are essential for better clinical and functional Outcomes and to avoid the permanent disabilities.(17)
In conclusion, actinomycetoma Osteomyelitis radius is rare condition. Clinicians in endemic areas must Consider mycetoma osteomyelitis as a differential diagnosis when they are dealing with vague atypical Musculoskeletal destructive lesions. Multidisciplinary team and Triple assessment including clinical, Radiological and histopathological correlation are extremely important to prevent misdiagnosis, surgical Treatment in combination with medical treatment followed by regular clinical and radiological follow up Can be limb saving procedure in such cases. Finally, treatment of mycetoma osteomyelitis cases is case By case individually according to the predictors of post-operative recurrence.(17)