Successful treatment of human eumycetomas caused by Aspergillus species with voriconazole



Eumycetoma, voriconazole, Aspergillus niger, Aspergillus flavus, Aspergillus fumigatus.


  Background Mycetoma is a chronic, granulomatous infection of skin, soft tissues and bones which developed after traumatic inoculation of pathogenic spores deep in to the tissues. Classical triad consists of swollen tissues, draining sinuses and coloured grains.  Objective This study aimed to document clinical impact, side effects and safety profile of voriconazole in Aspergillus eumycetomas.  Methods Retrospective study of clinical, histopathological and culture proven cases of Aspergillus eumycetomas treated with voriconazole between October 2017 to March 2020. Voriconazole 400 mg/day was given for six to 15 months.  Results Six patients were selected for the study. Male to female ratio was 1:1. Mean age of cases was 45.33 years; five belonged to rural areas; most common occupation was farmer; feet were involved in five while knee was involved in one case only. Mean delay in diagnosis was 9.33 years. KOH mount showed filamentous, septate, acute-angled, dichotomously branched hyphae in all cases. Histopathology was diagnostic in four cases. Culture was positive in all cases and reported Aspergillus flavus in three, Aspergillus niger in two and Aspergillus fumigatus in one case. Bone involvement was none to minimal. Cultures became negative after three months of therapy while clinical improvement required at least six months of drug treatment. Surgical intervention was required in four cases. None of the case ended up for amputation. Five cases achieved complete clinical and microbiological cure.  Conclusion Voriconazole is safe and efficacious for treatment of eumycetomas caused by Aspergillus species.

Author Biographies

Yousuf Abd Mallick, The Indus Hospital, Karachi, Pakistan

Consultant in Dermatology department at The Indus Hospital, Karachi, Pakistan.

Nausheen Yaqoob, The Indus Hospital, Karachi, Pakistan

Section Head and Senior Consultant Histopathologist in Histopathology Unit at The Indus Hospital, Karachi, Pakistan,

Kanwal Aftab, The Indus Hospital, Karachi, Pakistan

Consultant Histopathologist in Histopathology Unit at The Indus Hospital, Karachi, Pakistan.

Fahad Abd Mallick, Abbasi Shaheed Hospital, Karachi, Pakistan

2nd year Resident of General Surgery in Surgical Unit III at Abbasi Shaheed Hospital, Karachi, Pakistan.

Qurat ul Ain Zahid, The Indus Hospital, Karachi, Pakistan

1st year Resident of Microbiology in Microbiology Unit at The Indus Hospital, Karachi, Pakistan.



Verma P, Jha A. Mycetoma: reviewing a neglected disease. Clin Exp Dermatol 2019;44:123-9.

Welsh O, Salinas-Carmona MC, La Garza JAC, Rodriguez-Escamilla IM, Sanchez-Meza E. Current treatment of mycetoma. Curr Treat Options Infect Dis 2018;10:389–96.

Reis CMS, Reis-Filho EGM. Mycetomas: an epidemiological, etiological, clinical, laboratory and therapeutic review. An Bras Dermatol 2018;93:8-18.

Fahal AH, Sabaa AHA. Mycetoma in children in Sudan. Trans R Soc Trop Med Hyg 2010;104:117–21.

Zijlstra EE, van de Sande WWJ, Welsh O, Mahgoub ES, Goodfellow M, Fahal AH. Mycetoma: a unique neglected tropical disease. Lancet Infect Dis 2016;16:100-12.

Fahal A, Mahgoub ES, Hassan AME, Abdel-Rahman ME. Mycetoma in the Sudan: an update from the Mycetoma Research Centre, University of Khartoum, Sudan. PLoS Negl Trop Dis 2015;9(3):e0003679.

Mallick YA. An unusual case of mixed mycetoma by actinomycete and aspergillus species. Pak J Med Dentistry 2020;9:113-6.

Bennett JW. An overview of the genus Aspergillus. In: Bennett JW, editor. Aspergillus: molecular biology and genomics. Poole: Caister Academic Press; 2010. p. 1-17.

Ahmed SA, Abbas MA, Jouvion G, Al-Hatim AM, de Hoog GS, Kolecka A, et al. Seventeen years of subcutaneous infection by Aspergillus flavus; eumycetoma confirmed by immunohistochemistry. Mycoses 2015;58:728-34.

Mallick YA, Yaqoob N. Aspergillus niger causing eumycetoma in an immunocompetent host: report of a case and review of the literature. J Dow Univ Health Sci 2020;14:42-4.

Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, et al. Practice guidelines for the diagnosis and management of Aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis 2016;63:e1-e60.

Aspergillus & Aspergillosis website [Internet]. What is aspergillus? c2006 [updated 2018; cited 2020 July 15]. Available at:

Zaman SU, Sarma DP. Maxillary sinus mycetoma due to Aspergillus niger. Internet J Otorhinolaryngol 2006;6(1):1-4.

Drugbank [Internet]. Voriconazole; c2005. [updated 2020 July 11; cited 2020 July 15]. Available at:

Hopps S, Roach A, Yuen C, Borders E. Treatment for a eumycetoma infection caused by Aspergillus in an immunocompromised host: a case report. Transpl Infect Dis 2015:17:94–7.

Porte L, Khatibi S, Hajj LE, Cassaing S, Berry A, Massip P, et al. Scedosporium apiospermum mycetoma with bone involvement successfully treated with voriconazole. Trans R Soc Trop Med Hyg 2006;100:891–4.

Padhi S, Uppin SG, Uppin MS, Umabala P, Challa S, Laxmi V, et al. Mycetoma in South India: retrospective analysis of 13 cases and description of two cases caused by unusual pathogens: Neoscytalidium dimidiatum and Aspergillus flavus. Int J Dermatol 2010;49:1289–96.

Tendolkar U, Sheth B, Baveja S, Mehta N, Samaddar A, Banshelkikar S, et al. Unusual presentation of Madurella mycetomatis mycetoma in a paediatric patient in India. MOJ Clin Med Case Rep 2016;4(5):109-11.

Rudramurthy SM, Paul RA, Chakrabarti A, Mouton JW, Meis JF. Invasive aspergillosis by Aspergillus flavus: epidemiology, diagnosis, antifungal resistance, and management. J Fungi 2019;5:55.

Verweij PE, Ananda-Rajah M, Andes D, Arendrup MC, Brüggemann RJ, Chowdhary A, et al. International expert opinion on the management of infection caused by azole-resistant Aspergillus fumigatus. Drug Resist Updat 2015;21-22:30-40.






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