Role of a NSAID in the apparent cure of a fungal mycetoma.

Summary We report the case of a fungal mycetomadue to Madurella mycetomatisthat failed to respond to surgery and antifungal treatment but responded strongly to the addition of a non-steroidal anti-inflammatory drug (NSAID). This African patient was born in Mauritania in 1972. He was a herdsman, living close to the Senegal River. The first nodules appeared on the left foot at the age of 13 years (1985). The patient suffered frequent flare-ups with the appearance of black grains and underwent surgery in 1988 and 1992 in Senegal. After remission for several months after surgery, new fistulae occurred. The patient emigrated to France in 1995 and underwent a third surgical intervention in 1996. M . mycetomatis was cultured from the black grains . The patient was otherwise in good health, with no diabetes, and HIV tests were negative. We saw the patient for the first time in 2005, at which time he had flare-ups every two to three months. Imaging disclosed an absence of bone involvement. The patient underwent a fourth operation in October, 2005, and voriconazoletreatment was initiated. A new flare-up occurred in February, 2006. CT, MRI, and PET scans revealed calcaneusand tarsal involvement, and posaconazolethen replaced voriconazole. Flucytosinewas added four months later, due to an absence of improvement. New flares-ups occurred and a fifth surgical intervention was performed in September, 2006. The pain, which had been present for three years, worsened; the patient had to stop working and was no longer able to walk without crutches. Amputation of the foot was considered. Empiric treatmentwith a NSAID, diclofenac (Voltaren ® ; 100 mg/day), was added to the antifungal treatment in November 2006, to treat the patient's pain and inflammation. A major improvement was observed within one week. The patient was able to walk without crutchesone month later. After two months, clinical examination was normal: no pain, inflammation, nodules or fistulae. Flucytosinewas stopped after six months of treatment, in January 2007, diclofenac after 10 months, in October 2007, and posaconazoleafter 18.5 months, also in October 2007. No relapse has occurred during the eight years of follow-up since treatment ended. The patient seems to have been cured and has normal CT, MRI, and PET scans. In summary This eumycetoma, which had progressed over 20 years despite surgery and antifungal treatments, seems to have been cured by the addition of a NSAID. This observation suggests that inflammation plays a major role in the pathogenesis of fungal mycetoma. Clinical studies of treatments including an NSAID should be conducted to confirm this finding.