A 50-year-old female patient presented to our hospital- Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia- with worsening pain in her right foot and difficulty walking for 2 months. The patient had a history of TB treatment two years ago after an x-ray diagnosis of right ankle joint TB was made at a remote hospital after she presented with pain and swelling in the right ankle for five years. However, she saw only minimal improvement after completion of anti-TB treatment.
On physical examination at her presentation to our hospital, she appeared healthy and had normal vital signs. There was swelling and mild tenderness in the right ankle and metatarsal tenderness in the right foot, but no deformity or swelling.
Laboratory tests revealed a normal complete blood count with a white blood cell count of 6.1 x 103 cells per microliter and hemoglobin of 10 g/dl. The ESR was 10 mm/h and the renal and liver function tests and urinalysis were normal. Uric acid level was determined to be 2 mg/dl and Fasting blood sugar was 95 mg/dl. Gram stain of the lesion was positive for gram positive cocci. No growth was evident in the bacterial culture. Histopathologic examination was not done due to an inadequate tissue sample. A plain radiograph showed lytic lesions involving the navicular and cunifom bones as well as the metatarsal bases. (Fig. 4).
With a diagnosis of non-specific arthritis, she was started on a 100 mg suppository of indomethacin to be taken as needed. However, a follow-up visit three months later found no improvement in symptoms. At this time, an ankle MRI was also done to make a diagnosis and look for complications such as osteomyelitis. There were multiple rounded lesions of varying sizes diffusely involving the subcutaneous tissue, muscles, and bones of the right ankle and foot. The lesions were hyperintense having a central hypointense dot and a peripheral rim of hypointensity in T2 and PDW SPAIR, and showed contrast enhancement (Fig. 5). There were also diffuse marrow changes of the hind, mid, and forefoot bones, except the calcaneous and cuboid. A minimal amount of ankle joint fluid collection was also seen. Tendons, ligaments, and aponeurosis appeared normal.
A diagnosis of Madura foot was made and the patient was treated with fluconazole and cotrimoxazole and indomethacin was continued. The patient is complying well with her medications and has seen significant improvements after six months of treatment.