Case presentation
A 40 year old female farmer from Sudan referred to our orthopedic oncology clinic at Ibrahim Malik Teaching Hospital –Sudan, complaining of chronic right distal forearm pain, swelling and numbness for two years, it started with small painless lump that over period of time increased in size gradually, recently her quality of life and functional status had been massively affected due to increasing pain intensity, increase symptoms anguish and constant decrease in range of motion at the wrist joint. Patient were ill but not pale, no loss of weight neither constitutional symptoms were noted, vital signs were within normal range. No Sinuses were noted throughout the course of presentation. Conventional xray show right distal radius mixed lytic and sclerotic bone lesion with sunburst periosteal reaction and soft tissue swelling [fig1] . Initially and with inadequate assessment, she was suspected with osteosarcoma distal radius, thus she was referred. No advance imaging requested, or biopsies were taken. Since then the deterioration in her general condition had been growing steadily. Painful activity of daily living agonized the patient, swelling and limitation of movement on the affected side had been worsening dramatically. Furthermore she ended by using daily pain killer for long time. On clinical examination there was obvious right distal forearm swelling and tenderness mainly at the radial and dorsal side of the forearm, the mass was irregular in shape, hard in consistency measured about 7*3 cm, with mild temperatures asymmetry compared with adjacent skin, no sinuses were identified lymphatic streaks. Hematological investigations were unremarkable, X-ray revealed the same findings and MRI of right wrist show right distal forearm swelling (enhancement) incasing distal neurovascular bundle , pre-tumor edema , no skip lesions[fig2-3]. CT chest & chest X-ray were normal, no evidence of metastases. At this point the decision was to take core biopsy under general anasthesia. Histopathology analysis reports multiple grains of streptomyces somaliensis surrounded by granulasion tissues with gaint cell granuloma, the features of actinomycetoma consistent with streptomyces somaliensis[fig4] . Second surgery i.e. wide local excision and fixation was done and second biopsy were taken, confirming the diagnose.
After two months from operation the patient’s condition improved and referred to mycetoma center in Soba hospital for medications [fig5] .