Case contributed by Dr Arvind Aggarwal


Painless swelling with multiple sinuses involving left foot for 3 years.

Patient Data

Age: 50 years
Gender: Male

Radiographs of left foot demonstrate very advanced bony destruction, with a palisade type of periosteal reaction, with multiple sinuses and cortical erosions mainly involving tarsal and metatarsals .


Selected images form an MRI of  left foot demonstrate a soft tissue mass involving the left foot, the mass showed conglomerate areas of multiple, discrete, small 2–5 mm round hyperintense lesions, which were separated by a low-signal-intensity rim and central hypointense dot  infiltrating the adjacent muscles.

T2-weighted MRI revealed diffuse hyperintensity involving the subcutaneous tissue, muscles, and intermuscular fascial planes, with multiple pockets of fluid collections with overlying skin ulceration . Also, multiple small discrete spherical hyperintense lesions were noted, which were divided by a network of low-intensity soft tissue. In the center of some of these lesions, there was a tiny hypointense focus, resulting in the dot-in-circle sign. Small conglomerated low intensity foci and micro-abscesses were also seen at other sites.  


Hematoxylin and eosin (H&E) stain: fungal organisms surrounded by granulation tissue. 

Case Discussion

This case demonstrates fairly typical appearances of advanced Madura foot (maduromycosis) of three years duration. 

Maduramycosis is a chronic granulomatous fungal disease affecting lower limbs especially the foot . Disease is caused by the filamentous fungi which when introduced into the human body by prick of infected thorn or splinter. Typical clinical findings of the disease helps to make a diagnosis which includes , painless wound involving the part of a limb with multiple discharging sinuses for a long time , having yellow colored discharge resembling small grains which are, in fact, clumps of fungi (also found in biopsy).

Furthermore, as these fastidious organisms sometimes are difficult to demonstrate either on biopsy or microbiological culture, or when the clinical and biopsy findings are equivocal, MRI scan helps to make the diagnosis.

The recently described "Dot in circle sign" is the characteristic for Madura foot. 

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Case information

rID: 29099
Published: 10th May 2014
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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