A 15-year-old male patient from the Afar region, Ethiopia, presented to our hospital with a chronic wound on the dorsum of his right foot with sinus tracts that intermittently drained brown purulent discharge. Eight years earlier, he had stepped on a wood while walking barefoot; otherwise, he has no symptoms suggestive of tuberculosis (TB) or close contact with TB patients and is HIV seronegative. He was treated with several courses of antibiotics at a local health center for the above complaints, but the symptoms continued to worsen. On physical examination at presentation, he had a large, nodular, nontender mass on the dorsal aspect of the right foot with multiple sinus tracts that were not draining fluid (Fig. 1).
Right foot radiographs of the patient showed well-defined semicircular erosions on the lateral margin of the first proximal phalanx with adjacent solid periosteal reaction and associated soft-tissue swelling over the forefoot (Fig. 2).
Further examination of the patient with US of the right ankle and foot revealed a lesion with a heterogeneous echo pattern on the dorsum of the right foot, containing multiple hypoechoic thick-walled lesions with small sharp hyperechoic foci (dot-in-circle sign) (Fig. 3). Color Doppler showed increased vascularity in the surrounding soft tissue. An MRI was planned, but the patient's parents could not afford the cost. A core needle biopsy was taken from the lesion, and it was suggestive of an actinomycetoma. The patient received treatment with itraconazole and co-trimoxazole for eight months with little improvement in symptoms. He is transferred to orthopedic surgery unit for possible surgical intervention.