Fig. 6.20. A The longitudinal section of an amputated foot with severe mycotic infection, causing deep abscesses and marked destruction of all the tissues. (The same patient from Uganda as Fig. 6.9 D.). B In this excised specimen from Australia the black grains are surrounded by pyogranulomatous foci. C The clinical patterns of mycetoma: 1 A subcutaneous nodule; 2 superficial plantar nodules; 3 nodules deep to the plantar ligament with diffuse bone invasion; 4 primary foci within bone; 5 primary periosteal foci; 6 spread to lymph nodes. D The grains of the different fungi are usually easy to recognize on histological section. 1 Actinomadura pelletieri; 2 Leptosphaeria senegalensis; 3 Actinomadura madurae; 4 Streptomyces somaliensis; 5 Nocardia brasiliensis; 6 Madurella mycetomi (sections 1, 4 and 6 courtesy of Professor R. Camain). E Sometimes the cause of the infection can be found, as in the case of this thorn embedded in the soft tissues surrounded by multiple fungal colonies. F Occasionally such splinters are visible on radiographs, as on the medial side of the first metatarsal joint of this young African. (A courtesy of Dr. D. H. Connor; B courtesy of Dr. Ian S. Wilkey; C from W .W. Davey: Companion to surgery in Africa. Edinburgh, E. & S. Livingstone, 1968)

Fig. 6.21 A-C. Madura foot caused by three different types of fungal infection. A Marked soft tissue swelling around infection of the fifth metatarsal, spreading to the edge of the fourth metatarsal (Nocardia). B A spiculated infection of the shaft of the first metatarsal, not involving any other part of the foot (S. somaliensis). C A destructive infection, but with less periosteal reaction, involving the proximal end of the second metatarsal and spreading up the shafts of the third and fourth metatarsals. The adjoining tarsal bones are also infected (Madurella). (Courtesy of University of Capetown Radiology Library)

Fig. 6.22 A-D. Advanced madura foot. Tarsal infections can be very destructive of both soft tissues and bone, but many patients complain more of the size of the foot and difficulty in walking, rather than of pain. In D the infection may be burned out and there is bony fusion across the joints. This patient was only 34 years old. Patients A and B came from Zimbabwe and Kenya, patients C and D from India. (C, D courtesy of Professor Harold Jacobson)