Subcutaneous mycoses: Endemic but neglected among the Neglected Tropical Diseases in Ethiopia

Abstract

Background: Subcutaneous (deep) mycoses are a chronic infectious disease of the skin and underlying structures endemic in tropical countries. The disease has serious medical and socioeconomic consequences for patients, communities and health services in endemic areas. The inclusion of mycetoma and other subcutaneous mycoses in the list of Neglected Tropical Diseases by WHO highlights the need to assess the burden of these diseases and establish control programs where necessary. In Ethiopia no strategies can be devised because of a lack of epidemiologic information. To address this evidence gap, we performed a national rapid assessment of the geographic distribution of subcutaneous mycoses.

Methodology: We conducted a rapid retrospective assessment using hospital records to identify all suspected and confirmed cases of subcutaneous mycoses in 13 referral hospitals across the country between 2015 and 2022. In each hospital the logbooks were reviewed for diagnoses of subcutaneous mycosess, as diagnosed per routine practice. Descriptive analysis was done.

Result: From 13 hospitals we extracted 143 cases of subcutaneous mycoses, registered from July 2018 to September 2022. 118 (82.5%) patients were diagnosed as mycetoma, 21 (14.7%) as chromoblastomycosis and the remaining 4 (2.8%) as sporotrichosis. The mean age of patients was 35.8 years (SD = 14.5). 101 (70.6%) patients were male and 96 (67.1%) patients were farmers. 64 (44.8%) cases were from the Tigray regional state. 56 (65.9%) patients had information on diagnostic microscopic evaluation: for mycetoma histopathologic evaluation and fine needle aspiration cytology had a higher positivity rate while for chromoblastomycosis potassium hydroxide (KOH) staining had a better yield. The main clinical presentations were nodules, sinuses and infiltrative plaques on the skin. Radiologic findings of bone involvement was present in some.

Conclusions: Mycetoma and other subcutaneous mycoses are endemic in Ethiopia, with cases reported from almost all regions with the highest cases numbers reported from the northern part of the country. A routine program and systems should be developed to identify and document the burden of subcutaneous fungal infections in the country. Diagnosis and treatment guidelines should be developed.

Fig 1. Regional distribution of subcutaneous mycoses in Ethiopia, seen at referral hospitals from data registered from July 2018 to September 2022 (Source Ethio_GIS, 2019).

Fig 2. Mycetoma and the different body site affected from cases seen in referral hospitals in Ethiopia.

A) Woody hard globular swelling of the left foot with multiple sinuses. B) Infiltrative plaques on the sole of the left foot medially with sinuses and grains. C) Multiple nodules and sinuses on the right upper back extending to the shoulder. D) Hard to rubbery infiltrative plaque on the lower chest and upper abdomen with papules, nodules and sinuses. E) & F) A patient with both buttock and genital involvement. Infiltrative mass on the right buttock with multiple sinuses and hyperpigmented infiltrative involvement of the pubic area of the external genitalia with tumorous enlargement of the labia.

Fig 3

A) Sporotrichosis; swollen ring finger with crusting, nodular lesions on dorsum of hand and wrist linearly arranged. B) Sporotrichosis; infiltrative plaque with satellite papules. C) Chromoblastomycosis; warty papules and nodules covering the lower leg and dorsum of foot. D) Chromoblastomycosis; Ulcer, hemorrhagic crust and warty papules on the lower leg.