Subcutaneous mycoses: Endemic but neglected among the Neglected Tropical Diseases in Ethiopia

BackgroundSubcutaneous (deep) mycoses are a chronic infectious disease of the skin and underlying structures endemic in tropical countries. The disease has serious medical and socioeconomic consequences for patients, communities and health services in endemic areas. The inclusion of mycetoma and other subcutaneous mycoses in the list of Neglected Tropical Diseases by WHO highlights the need to assess the burden of these diseases and establish control programs where necessary. In Ethiopia no strategies can be devised because of a lack of epidemiologic information. To address this evidence gap, we performed a national rapid assessment of the geographic distribution of subcutaneous mycoses.MethodologyWe conducted a rapid retrospective assessment using hospital records to identify all suspected and confirmed cases of subcutaneous mycoses in 13 referral hospitals across the country between 2015 and 2022. In each hospital the logbooks were reviewed for diagnoses of subcutaneous mycosess, as diagnosed per routine practice. Descriptive analysis was done.ResultFrom 13 hospitals we extracted 143 cases of subcutaneous mycoses, registered from July 2018 to September 2022. 118 (82.5%) patients were diagnosed as mycetoma, 21 (14.7%) as chromoblastomycosis and the remaining 4 (2.8%) as sporotrichosis. The mean age of patients was 35.8 years (SD = 14.5). 101 (70.6%) patients were male and 96 (67.1%) patients were farmers. 64 (44.8%) cases were from the Tigray regional state. 56 (65.9%) patients had information on diagnostic microscopic evaluation: for mycetoma histopathologic evaluation and fine needle aspiration cytology had a higher positivity rate while for chromoblastomycosis potassium hydroxide (KOH) staining had a better yield. The main clinical presentations were nodules, sinuses and infiltrative plaques on the skin. Radiologic findings of bone involvement was present in some.ConclusionsMycetoma and other subcutaneous mycoses are endemic in Ethiopia, with cases reported from almost all regions with the highest cases numbers reported from the northern part of the country. A routine program and systems should be developed to identify and document the burden of subcutaneous fungal infections in the country. Diagnosis and treatment guidelines should be developed. Subcutaneous mycoses (fungal infections) are a chronic infectious disease of the skin and underlying structures endemic in tropical countries. These diseases are considered neglected tropical diseases, with significant health and socioeconomic impacts on patients and communities. However, there is a lack of epidemiological information about these diseases in Ethiopia. To address this gap, a national rapid assessment was conducted using hospital records to identify all suspected and confirmed cases of subcutaneous mycoses in 13 hospitals in different regions of the country between 2015 and 2022.The rapid assessment conducted in Ethiopia revealed that the country is endemic for mycetoma and other subcutaneous mycoses, with cases reported from almost all regions but with variations in case distribution. This study constitutes the largest number of cases reported from Ethiopia, and the first to cover all main geographical areas across the country. More than two third of cases reported are from the northern part of the country (Tigray and Amhara region) alone, despite the fact that these regions comprise only about a quarter of the total population of the country. At the same time, the smaller number of cases (143) registered in almost 5 years indicate a lower prevalence compared to Sudan, a neighbouring country which has reported more than 9600 cases over a span of 30 years.The authors noticed, there is a lack of research and surveillance programs for subcutaneous mycoses, and more accurate data and national mapping of the disease are needed. A routine program and systems should be developed to identify and record cases of subcutaneous mycoses at all levels of healthcare, including primary healthcare, and public awareness and education efforts should be intensified.In conclusion the findings of this rapid assessment underscore the need for increased attention to subcutaneous mycoses in Ethiopia. The scarcity of research and surveillance programs for these infections highlights the urgent need for developing routine programs and systems for identifying and recording cases of subcutaneous mycoses in health care system, along with revising the health information system indicators to capture skin neglected tropical diseases, would be valuable steps. These efforts should be combined with public awareness and education campaigns targeting community workers and health professionals to improve identification and referral of patients.

Automated summary

Subcutaneous mycoses are endemic in Ethiopia, with cases reported throughout the country, especially in the northern regions. The lack of research and surveillance programs for these diseases highlights the need for routine programs and systems to identify and record cases.