1. CASE PRESENTATION What is the diagnosis?? 04/09/2015 Dr. J. Jagoda – Consultant Rheumatologist/DGH Gampaha Dr A. P. J. Cooray – Senior Registrar-Rheumatology/RRH Ragama

2. Mr. P : 37 year old driver - 2003 • Mild discomfort and a lump in the anterior aspect of the knee • No other joint swelling • No fever • No rash • No recent history of an illness • No trauma

3. Visits a Consultant Physician • Some blood tests were done • ?ESR/FBC – were said to be normal • Reassured and given painkillers • Lump regresses leaving behind an indurated area of skin and another two appear at different locations • Ignored by the patient • Not painful • No discharge • No systemic illness • Heal with scarring

4. 2005 – He goes to the Surgeon • Lump reappears at a different location • Discharges grainy material • Previous scars also start discharging • FBC – Thrombocytosis, ESR 39mm • X-Ray: Soft tissue swelling with periosteal reaction • US scan : 4.5/2.0 cm cystic lesion superficial to the Tibia. Impression is that of a chronic abscess

5. Superficial nodule is excised - 2005 • Histopathology report ; fibro connective tissue shows foci of eosonophillic crystalline material surrounded by neutrophills and pallisades of histiocytes. The stoma shows sheets of inflammatory cells Conclusion; The features are compatible with gout #Uric acid – 2.6mg/dl

6. Severe knee pain with joint swelling - 2009 • Fluid aspirated out from KJ • Full report and culture sent • Mantoux test negative • Chest X ray – nothing to suggest TB

8. Pain relief is given – feels well till 2013 ( Still has discharging nodules) • Tries ayurvedic treatment • Severe pain in KJ with swelling and fever • Goes to a Consultant Rheumatologist • WBC 11.6 * Neutrophill predominent, Platelets 691000 • ESR 130mm/CRP 96mg/dl • Aspirated out • MRI done • Arthroscopic synovial biopsy arranged

9. MRI report

10. Pigmented villonodular synovitis • A benign proliferative disorder of the synovium • Clinical pattern • Isolated tenosynovitis (Tenosynovial giant cell tumour) • Diffused form • Localized form

11. MRI – characteristic appearance: Low signal intensity lesion in T1/T2 sequences

12. Histopathology – synovial proliferation with foam cells & haemosiderin laden giant cells

14. Antibiotics for 2 weeks and pain relief • ROM is now diminished • Multiple scar marks on his left knee • New subcutaneous nodules keep appearing • But no other joint involvement • He is feeling well i.e no fever, no night sweats, no loss of weight

16. Back to our patient - 2014 • Multiple discharging nodules with stiffness of the knee • ESR – 52mm • Normal FBC • FNAC of nodule : suppurative inflammation • Synovial biopsy repeated • Trial of ATT considered

17. What can it be? • Bone and joint TB • Gout • Rheumatoid arthritis • Tumour • Some other rare cause

18. BIOPSY REPORT 2014

19. Mycetoma • Chronic granulomatous subcutaneous infection • Aetiology • Actinomycetes – A.Pelletieri, A.Madurae, Nocardia sps • Fungi – P.boydii, M.Mycetomatosis

20. Clinical phases • Painless subcutaneous swelling • Indurated area • Subcutaneous nodule • Spread to contiguous tissue • Sinus tracts – sulphur granules

21. Diagnosis • Imaging • Radiography/CT • US scan • MRI • Laboratory diagnosis • Histopathology • Culture

22. Features Cortical thickening Periosteal reaction Lytic lesions

23. Features 1. Dot in circle sign

24. Histopathology • FNAC or wedge biopsy • Synovial biopsy • Gram stain/Geimsa stain

25. Identifying the causative organism Actinomycetoma Eumycetoma • Filamentous bacteria • Gram positive • 01 micrometer or less • Periphery is basophillic and the center is eosonophillic • Large grains • True fungai with hyphae and many chlamydophores • Gram negative • 2-4 micrometers • Large grain is 5mm or more

26. Management Actinomycetoma Eumycetoma • Co-trimaxozole • Dapsone and Streptomycin • Rifampicin • Gentamycin • Penicillin • Itraconazole

27. Do we finally have a diagnosis • ? Is it eumycetoma or actinomycetoma

28. Thank you • Acknowledgements • Dr C.S.P Sosai – Consultant Histopathologist • Dr P. Rathnayake – Consultant Histopathologist • Dr M. Kothalawela – Consultant Microbiologist