TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE (1996) 90,675-676 675 IShort Reportl Pathological fracture in mycetoma A. H. Fahal’, H. E. SheikhZ and A. M. El Hassan3 Departments of ‘Surgery, ZRadiology and 3Pathology, Faculty of Medicine, University of Khartoum, Khartoum, Sudan Keywords: mycetoma, Madurella mycetomatis, fracture Case report Pathological fracture caused by mycetoma has not pre- viously been described in the literature. Here we report a patient with long-standing mycetoma who presented with a pathological fracture of the left tibia. The patient was a 25 years old male from western Su- dan who reported to the mycetoma clinic at Soba Uni- versity Hospital, Sudan, with a massive mycetoma in- volving the left knee joint and upper part of the tibia. The condition had started 5 Years before admission as a were not contributory. On examination the patient was ill, weak, depressed, pale, and unable to walk. Head and neck, cardiovascular and respiratory systems, and abdominal examination were normal. Local examination revealed a huge subcutaneous mass over the upper part of the left tibia and the knee joint, measuring 21 x 12 x2 cm. Offensive pus and black grains were discharging through multiple sinuses. There was deformity, tenderness, click, and abnormal movement in the upper third of the tibia. The knee joint was fixed in a flexion position. The leg distal to the mycetoma lesion was oedematous. The inguinal lymph nodes were en- larged and tender. Antibodies against Madurella myceto- matis antigen were detected by counter-immunoelectro- phoresis. A radiograph of the left knee joint revealed a huge soft tissue mass, periosteal reaction with a sun ray appear- ance, severe bone destruction, and a fracture at the metaphysis of the tibia (Figure). The radiological differ- ential diagnosis was osteogenic sarcoma and bone tuber- culosis. The patient underwent above-knee amputation and had an uneventful post-operative recovery. Histo- Figure. X-rays of the left knee joint, showing a huge soft tissue mass, periosteal reaction, severe bone destruction, and fracture at the metaphysis of the tibia. a, Antero-posterior view; b, lateral view. small painless mass in the upper part of the medial as- pect of the tibia which gradually progressed and eventu- ally multiple sinuses discharging black grains developed. Three weeks before admission the patient became un- able to walk and experienced pain in the tibia and knee joint. His past medical, family, social or drug histories Address for correspondence: Mr Ahmed Hassan Fahal, Depart- ment of Surgery, Faculty of Medicine, P.O. Box 102,Khartoum, Sudan. pathological examination of the specimen showed grains and inflammatory reaction characteristic of M. myceto- matis; there was no evidence of malignancy. Comment A variety of radiological changes may be seen in my- cetoma depending on the causative agent and the effect of the granuloma on the bone blood supply (COCK- SHOTT, 1968). The following 3 types have been described (DAVIES, 1958). (i) Soft tissue granuloma which may ap-