Vignette 62: A 62 year old woman from Madurai (or Madura), 50 km SW of Vellore, presented at the Christian Medical Hospital in Vellore with a 7 year history of draining sinuses from various parts of the right hand.They had started several weeks after a scorpion bite on the that hand. Multiple courses of antibiotics and other treatments would help transiently. X-rays at the time of the visit are seen here. What is your diagnosis?
		Vignette provided by Mike Libman, McGill Centre for Tropical Disease. Case seen at the Second International Short Course in Clinical Tropical Medicine, at the Christian Medical College, Vellore, India, 2008 c/o Dr. Dilip Mathai, Internal Medicine Unit 1.

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Vignette 62: This is a "Madura hand" from "Madura". A culture grew Actinomadura madurae. It is an Actinomycetoma, not a Eumycetoma as seen in an earlier vignette (see). Granules from a biopsy (seen in H&E stain below right) were crushed and showed the gram positive branching filaments (below left).

Madura foot was first described by Gill in 1842 from a dispensary in Madura (now called Madurai). More cases were described by Garrison in Chennai not far from Madura. “Mycetoma” was coined by Carter in 1861. This patient was started on Trimethoprim/sulfamethoxazole alternating with streptomycin monthly with a plan to continue it for 1-2 years. Good data on optimal antibiotic management is lacking.