Expect the unexpected–a rare case report of lumbar spinal eumycetoma

Abstract

Mycetoma, a neglected disease found in tropical and subtropical countries, is a chronic granulomatous inflammatory disease affecting the subcutaneous tissue. The most common site of infection is the limbs, affecting around 80% of patients. Cases of cranial and spinal mycetomas are very rare. We are presenting an interesting case report of an intradural mycetoma in the lumbar region in an immunocompetent male with no discharging sinus. Notably, a 34-year-old man, presented with symptoms and signs suggestive of lumbar canal stenosis. On imaging with MRI (magnetic resonance imaging), an intradural lesion was observed at the L4-5 level of the lumbosacral spine. Given his history and imaging, an infective etiology, most probably tubercular, was suspected. He underwent L4-L5 laminectomy. During the procedure, pus was discovered extradurally, which was aspirated and analyzed. Upon opening the dura, grayish-black, moderately vascular, suckable grape-like black granules were observed. Sub-total excision of the lesion was performed, and a sample was sent for histopathology. The direct KOH smear showed septate fungal filaments. LPCB (lactophenol cotton blue) preparation revealed hyaline septate filaments with single-celled conidia and a truncated base, which was identified to be Pseudallescheria boydii. HPE (histopathological examination) report also concurred that the lesion was an eumycetoma. It is important to note that not all tumors in the lumbar canal are myxopapillary ependymomas, neurofibromas, metastatic bony lesions, or tuberculosis. There is a need to increase awareness and understanding of mycetoma, which would significantly improve disease management, particularly in the endemic areas.