Madura foot in the UK: Fungal osteomyelitis after renal transplantation

We report the case of an ethnic Asian patient who attended the renal transplant follow-up clinic complaining of pain in the right great toe. He had undergone transplantation nine months earlier and was maintained on triple immunosuppression. Initially, a clinical diagnosis of gout was made and the patient treated with analgesia. Two weeks later he remained symptomatic and developed a discharging sinus on his toe. A plain X-ray revealed a lytic lesion with minimal periosteal reaction. Aspiration of his first right metatarsal phalangeal joint was performed and fungal hyphae were observed in the fluid. Subsequently, despite surgical debridement and treatment with Itraconozaole amputation of the toe was required. Microbiological analysis revealed the organism to be Madurella grisea, which was resistant to both Itraconazole and Amphotericin B. He has remained well since amputation. We believe this to be the first case of Madurella infection to be described in a transplant patient.