From a Radiologist’s Eye: a Case Report of Actinomycetoma of the Foot With Comprehensive Review of Literature

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Madura foot, classified as a tropical disease by WHO, is a chronic granulomatous disease that predominantly involves the skin and subcutaneous tissue, commonly affecting the lower limbs. We present a case of actinomycetoma with extensive review of the existing literature, focusing on diagnostic imaging. Case presentation: A 36-year-old female from eastern India presented with a six-month history of right foot swelling and a discharging wound. She was unsuccessfully treated with multiple courses of antibiotics in local hospitals. Upon referral, radiological investigations were performed for further evaluation. USG showed infiltrative hypoechoic soft tissue with nodular lesions showing targetoid appearance. MRI revealed infiltrative soft tissue with variable sized nodular lesion showing characteristic ‘dot-in-circle' appearance, prompting the diagnosis of pedal mycetoma. Actinomycetoma was confirmed on biopsy. Conclusions: Pedal mycetoma presents significant diagnostic and therapeutic challenges owing to its insidious progression and delayed diagnosis. Radiological imaging, particularly MRI, plays a pivotal role in diagnosis and staging of the disease, enabling detailed evaluation of soft tissue and bone involvement. The ‘dot-in-circle' sign observed on imaging is pathognomic and aids in accurate diagnosis. Early diagnosis facilitated by diagnostic imaging warrants improved therapeutic outcomes. Infectious Diseases Nuclear Medicine & Medical Imaging Orthopedics Pedal mycetoma Madura foot Actinomycetoma Dot-in-circle Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Tropical diseases include a panel of communicable and non-communicable diseases that are prevalent along and between the tropic of Cancer and tropic of Capricorn belt (1). This includes infectious diseases like cholera, Malaria, HIV/AIDS, tuberculosis, leishmaniases, onchocerciasis, filariasis, trypanosomiasis, rickettsioses, etc. and non-communicable diseases such as malnourishment, hypertension, diabetes, chronic obstructive pulmonary disease, myocardial infarction and cerebrovascular accident (2). Madura foot has been classified by the WHO as an endemic disease of the subtropical and tropical areas (3). Madura foot is a chronic destructive granulomatous infectious disease involving the skin and subcutaneous tissue. It commonly affects the limbs, specifically the foot and ankle. However, it can also involve the abdominal wall, chest wall or head and neck region. Mycetoma of the foot is the most common form and is termed as mycetoma pedis or pedal mycetoma. Based on the causative agent, mycetoma is classified as actinomycetoma (caused by actinomyces) or eumycetoma (caused by Fungi). Owing to the non-availability of any large-scale studies, the true incidence of mycetoma still remains uncertain. However, the proportions of actinomycotic and fungal aetiologies are approximately estimated as 60% and 40% respectively (4, 5). In this report, represent a case of actinomycetes, in a middle-aged female and review of existing literature with specific emphasis on multimodality diagnostic imaging. Case Report Clinical Details A female patient of 36 years from the eastern part of India presented with swelling of the right foot and a discharging wound since 6 months (Figure 1). Initially, it was diagnosed as chronic bacterial osteomyelitis, and she was unsuccessfully treated with multiple courses of enteral and parenteral antibiotics from local hospitals. Her hematological parameters were unremarkable except for reduced hemoglobin concentration (9 g/dl). Radiological Features In line with the ongoing diagnosis, she was referred for an ultrasonography to detect and quantify localized collection, if any. Ultrasonography (USG) revealed infiltrative ill-defined hypoechoic soft tissue in the dorsum and sole of foot with inflamed adjacent fat. Multiple discrete and confluent nodular lesions, in solitary and clustered distribution were seen within the soft tissue (Figure 2). These nodular lesions showed a central hyperechoic focus surrounded by hypoechoic tissue with a peripheral hyperechoic rim, giving target/ do-in-circle appearance. A linear hypoechoic sinus tract was seen reaching up to the overlying skin surface. For further evaluation, magnetic resonance imaging (MRI) was performed. MRI revealed nodular infiltrative soft tissue, involving the subcutaneous tissue and muscles of the sole and dorsum of foot. The soft tissue exhibited low signal intensity on T1 and heterogeneously high signal intensity on T2/ PD FS/ STIR. Multiple variable sized well-defined nodular lesions were scattered within the soft tissue appearing hyperintense on T2/ STIR with a peripheral hypointense rim and central hypointense foci, representing dot-in-circle sign (Figure 3). Extensive bone involvement was also seen (Figure 4). Moth- eaten pattern of bone destruction was seen involving the proximal ends of first, second and fourth metatarsals. Sclerosis of the adjacent bone was also seen. Solid periosteal reaction was seen along the second metatarsal. There was associated loss of normal T1 hyperintensity of the bone marrow with increase in PD FS/ STIR signal. Though the third and fifth metatarsals did not show obvious bone lysis or lesion, MRI revealed altered marrow signal intensity, representing involvement. Histopathology For confirmation of the diagnosis, a surface biopsy was performed. Histopathological examination with H&E staining revealed a focal colony of basophilic filamentous bacteria with peripheral Spleondore- Heoppli phenomenon. Filamentous bacteria stained positive on Grocott's methenamine silver (GMS) stain (Figure 5). Management In view of extensive bone involvement and local spread, an above knee amputation was planned. Patient was reluctant for the same and subsequently defaulted. Discussion Madura foot was recognized as a disease entity by Gill in the year 1842 at Madurai, India and was later termed ‘mycetoma’ by Carter in 1880 ( 6 ). It commonly affects those occupations that are in close contact with soil and vegetations such as farmers, cattle breeders, agricultural workers and poultry farmers. It usually involves parts of the body that are exposed to the soil like hands, feet and lower legs. Transdermal inoculation is the most common route of transmission, usually following trauma or penetrating injury ( 7 ). It is prevalent in patients between 20 to 40 years of age and demonstrates male predilection with a reported male-female ratio of 3.5: 1 ( 8 ). It is a sinister disease that painlessly spreads through the soft tissue to involve bones, rendering conservative management options futile. Clinically, it presents with a triad of features- painless foot swelling, multiple sinuses and discharging specific-colored grains ( 4 ). Though actinomycetoma and eumycetoma present with similar features, the former exhibits a rapid progressive course resulting in locally advanced and disseminated infection ( 9 ). Infection progresses in four stages ( 4 ). The first stage of the disease is incubation which can vary from a few weeks to years. Subsequently, the patients develop nonspecific features of local cellulitis like swelling and pain. As the pathogen proliferates in the subcutaneous plane, microabcesses with surrounding granulation tissue result in formation of subcutaneous nodules. As these nodules increase in size, they erupt the overlying skin surface forming discharging sinuses. Eventually, the disease extends into deeper tissue planes and involves bones causing significant soft tissue and osseous destruction. Deformity soon ensues destruction. In the advanced stages, diagnosis can be made readily based on classical clinical features. During the early indolent course of the disease, it is often misdiagnosed and unsuccessfully treated as common bacterial cellulitis. At the time of diagnosis, the disease is usually advanced with extensive soft tissue and bone involvement necessitating amputation. Hence, the challenge lies in early diagnosis of the disease. Radiological investigations, especially ultrasonography (USG) and magnetic resonance imaging (MRI) are indispensable modalities tools for early diagnosis. Plain radiographs can be normal in the early stage of disease but can demonstrate bone involvement and soft tissue thickening. However, computed tomography (CT) helps in better characterization of the pattern of bone involvement, periosteal reaction, presence of osteoporosis and bone destruction ( 10 ). Magnetic resonance imaging (MRI) is the imaging modality of choice aiding in excellent characterization of the soft tissue, associated extensions and infiltration, bone involvement and bone marrow edema. It also plays an indispensable role in pretherapeutic staging, evaluation of associated complications and therapeutic response assessment. Bone scintigraphy is another valuable tool for assessment of therapeutic response ( 10 ). The spectrum of radiological features comprises of various patterns of soft tissue and bone involvement. USG and MRI are the preferred tools for soft tissue characterization. On USG, it presents as an ill- defined hypoechoic infiltrative mass. Few authors have described increased color flow and Doppler signals within soft tissue which can be secondary to inflammation ( 11 , 12 ). On MRI, the soft tissue appears hyperintense on T2, PD FS and STIR sequences. It predominantly involves the subcutaneous tissue but frequently infiltrates the muscles and deeper soft tissue due to its aggressive nature ( 13 ), as observed in our case. The presence of ‘dot-in-circle' sign has been described as a specific hallmark for pedal mycetoma ( 11 – 14 ). It has been described in cases of both eumycetoma and actinomycetoma. The basis of ‘dot-in-circle' sign depends on the pathological organization of the granuloma which comprises of a central core of microbial elements (fungal hyphae or filamentous bacteria) surrounded by granulation tissue and chronic inflammatory infiltrate with a peripheral rim of fibrosis (Fig. 6 ) ( 15 ). It was first described by Sarris I et al in 2003 ( 16 ). However, the earlier available case reports also describe similar findings ( 17 , 18 ). On USG, it appears as a hypoechoic lesion with a central hyperechoic core and peripheral hypoechoic rim (Fig. 7 ). On MRI, this sign is best described on T2 FS, PD FS and STIR sequences in which these lesions appear hyperintense with a central hypointense focus and a peripheral hypointense rim (Fig. 8 ). T1 FS post contrast images have also been described to depict ‘dot-in-circle' sign but demonstrate no obvious advantage over non contrast sequences ( 15 ). However, post contrast images can additionally demonstrate the actual extent of soft tissue infiltration, associated collections, disease activity and subtle bone involvement. Diffusion weighted imaging (DWI) can aid in assessment of therapeutic response. Though few authors have not specifically reported ‘dot-in-circle' sign, Jimenez AL et al ( 19 ) reported the absence of the same in a case of eumycetoma which was initially misdiagnosed as synovial sarcoma. The presence of sinus tracts, hypoechoic on USG and hyperintense on T2/ STIR is another feature of mycetoma. Bone involvement includes bone destruction, sclerosis, periosteal reaction and resultant deformities. As a general observation, most authors have reported aggressive patterns of bone destruction of which moth- eaten pattern and permeative type are the most common ( 11 , 20 – 25 ). Aggressive forms of periosteal reaction such as interrupted, lamellated and spiculated patterns have been described as frequent associations ( 11 , 15 , 20 , 23 – 25 ). As in our case, few authors have also reported nonaggressive solid form of periosteal reaction ( 11 , 26 , 27 ). Martinez EI et al ( 28 ) described ‘snow melting’ pattern of bone involvement characterized by lytic bone destruction with surrounding florid dense sclerosis. The presence of bone marrow edema without obvious cortical involvement or bone destruction can represent early involvement. Hoogervorst LA et al ( 29 ) reported noncontiguous disseminated small hypointense lesions scattered within the tibial bone marrow in an immunocompromised patient without any bone involvement. Advanced long term disease results in extensive osteolysis, sclerosis and bony ankylosis ( 23 ). The salient radiological features that have been described in the earlier literature are summarized in table 1. Distinctive patterns of bone involvement in actinomycetoma and eumycetoma have been observed ( 15 , 20 ). Eumycetoma is associated with larger (usually > 1 cm in size) intraosseous cavities while Actinomycetoma causes moth- eaten pattern of bone destruction i.e., multiple punctate well-defined cavities. Gameraddin M et al ( 30 ) studied the differential sonographic and Doppler characteristics of eumycetoma and actinomycetoma. They reported that eumycetoma was associated with multiple aggregated grains, more heterogeneous echotexture and higher vascularity in comparison to actinomycetoma. Radiological staging of the disease is imperative for planning the treatment and patient counseling. In 2003, Abd El Bagi ME ( 31 ) devised a radiography- based system for staging bone involvement in pedal mycetoma (Table 2). Subsequently in 2013, El Shamy ME et al ( 32 ) proposed a detailed MRI- based mycetoma skin, muscle, bone (MSMB) grading system (Table 3) which comprises of three subscores- skin (scores 0–4), muscle (0–3) and bone (0–3). Out of a total score of 10, a score of 1–3 is considered mild, 4–7 is considered moderate and 8–10 is considered severe. Imaging also aids in evaluating the therapeutic response in patients on conservative management ( 10 , 33 ). Radiological features of healing are remodeling and sclerosis of the active edges of erosions, ossification of bone cavities and solid periosteal reaction, generalized bone sclerosis, resolution of bone marrow signal alteration, disappearance of granulomata (showing ‘dot-in-circle' appearance), reduced heterogeneity of soft tissue enhancement, normalization of diffusion restriction and normalization of increased uptake on bone scintigraphy. Due to painless and quiescent progression of the disease, numerous patients present with complications even at the time of initial diagnosis. Complications include periostitis, osteomyelitis, arthritis, bone destruction resulting in deformity, secondary bacterial infection, bacteremia and septicemia ( 9 , 34 ). Differential diagnoses include diabetic foot, localized bacterial cellulitis, osteomyelitis, Charcot arthropathy, venous thrombosis, tuberculosis and vascular tumors and malformations. Among these conditions, soft tissue collection with bone fragments in osteomyelitis, rice bodies in tuberculosis and phleboliths in vascular malformations can mimic ‘dot-in-circle' appearance. Clinicoradiological features that aid in differentiating these conditions are enumerated in table 4. Treatment of pedal mycetoma depends on the causative pathogen and stage of the disease. Actinomycetoma is treated with a combined regimen of antimicrobial agents including co-trimoxazole, dapsone, amikacin and tetracycline ( 35 , 36 ). Drug therapy of eumycetoma involves azole derivatives (itraconazole, voriconazole, fluconazole and miconazole) and co-trimoxazole. Surgical debulking of the disease might be necessary in case of larger lesions ( 37 ). Age > 59 years, lesion of size > 10 cm, duration of disease > 5 years and positive family history are predictors of recurrence following surgical debulking or excision ( 38 ). Locally advanced disease with bone involvement might require amputation of the limb. Conclusions Pedal mycetoma is a tropical granulomatous disease involving the soft tissue of the foot, caused by actinomyces or fungi. Radiological investigations form the main stay of diagnostic work up. USG and MRI are the preferred modalities for evaluation. MRI is an excellent tool for soft tissue characterization, evaluation of spread, bone involvement, staging and therapeutic response assessment. The presence of ‘dot-in-circle' sign is pathognomonic. Owing to its quiescent progression, the challenge lies in early diagnosis of the disease, underscoring the significance of diagnostic imaging. Early diagnosis also warrants good therapeutic outcomes. Abbreviations HIV/AIDS Human immunodeficiency virus/ Acquired immunodeficiency syndrome WHO World Health Organization USG Ultrasonography MRI Magnetic resonance imaging PD FS Proton density fat saturation T2 FS T2 fat saturation T1 FS T2 fat saturation STIR Short tau inversion recovery DWI Diffusion weighted imaging CT Computed tomography H&E Hematoxylin & Eosin GMS Grocott's methenamine silver MSMB Mycetoma skin, muscle, bone grading DECLARATIONS Competing interests The author(s) declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. Consent for publication Informed consent was obtained from patients to publish the case and use their radiological images involved in the preparation of this manuscript. Ethical considerations All procedures performed in this study involving a human participant were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Funding information The author(s) received no financial support for the research, authorship, and/or publication of this article. References Zumla A, Ustianowski A. Tropical diseases: definition, geographic distribution, transmission, and classification. Infect Dis Clin North Am. 2012; 26: 195-205. Cook G.C., Zumla A., editors. Manson's tropical diseases. 22nd edition. Saunders; London: 2009. p. 1830. Pierre- Jerome C, Kettner WN. The essentials of Charcot neuropathy. Elsevier; Amsterdam: 2022. P. 223-59. Karrakchou B, Boubnane I, Senouci K et al. Madurella mycetomatis infection of the foot: a case report of a neglected tropical disease in a non-endemic region. BMC Dermatol. 2020; 20: 1. 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No. Study Country No. of cases Type Soft tissue characteristics Presence of Dot-in-circle sign Pattern of bone involvement Periosteal reaction Deformity USG MRI 1 Leewall DB et al. 1985 (20) Saudi Arabia 30 19- A 11- E NR NR NR Sclerosis, cortical erosions, intraosseous cavities, moth- eaten pattern, osteoporosis Present (laminated/ spiculated/ bizarre)- 67% NR 2 Fahal AH et al. 1997 (17) Sudan 100 NR Hyperreflective grains surrounded by single or multiple thick -walled cavities NR NR NR NR NR 3 Czechowski J et al. 2001 (9) UAE 20 13- A 7- E NR Loss of normal signal intensity of the soft tissue with increased T2 signal NR Bone marrow abnormalities in 15 patients Bone destruction, erosions and coarsening of trabeculae Present NR 4 Ispoglou SS et al. 2003 (18) Greece 1 A NR Altered signal intensity of the affected soft tissue and bones, T1/ T2 hypointense ovoid lesions within the affected bones NR Mottled destruction of tarsals and metatarsals, sclerosis and bone marrow involvement Absent NR 5 Sarris I et al. 2003 (16) Reported in UK 2 E Case 1 Pakistan E Hypoechoic lesion with hyperechoic foci Hyperintense lesions separated by hypointense stroma on STIR with central low signal intensity evident on T1FS post contrast images. Yes NR NR NR Case 2 Nigeria E NR Follow up MRI- nonspecific inflammation with T2 hyperintense lesion showing central hypointensity Yes NR NR NR 6 Salamon LM et al. 2006 (39) USA 1 E NR Hyperintense subcutaneous lesion with internal hypointense foci NR Absent Absent NR 7 Cherian RS et al. 2008 (13) India 3 E Case 1 NR Conglomerate areas of multiple discrete, small round hyperintense lesions with peripheral low signal rim and central dot Yes Absent Absent NR Case 2 NR Infiltrative lesion involving the subcutaneous and muscular planes Yes Absent Absent NR Case 3 NR Extensive altered signal intensity involving the tarsals and soft tissue Yes Chronic osteomyelitis of tarsals NR NR 8 Asly M et al. 2010 (22) Morocco 1 E NR NR NR Bone resorpiton and permeative bone destruction diffusely involving the tarsals, metatarsals and phalanges NR NR 9 Jimenez AL et al. 2011 (19) USA 1 E NR Multiloculated well defined subcutaneous mass at the dorsum of distal foot Absent Absent Absent Absent 10 Elmaataoui A et al. 2011 (26) Morocco 2 E NR NR NR Geographic bone ill-defined bone destruction with sclerosis Present (solid) NR 11 Jain V et al. 2012 (21) India 1 E NR Extensive soft tissue and osseous inflammation, multiple discrete and confluent spherical lesions with hypointense rim, few showing central hypointense focus Yes Moth eaten type of bone destruction with articular erosions NR NR 12 El Shamy EM et al. 2012 (32) Sudan 42 (foot involvement in 25 patients) A- 24 E- 18 NR Ill-defined infiltrative soft tissue with multiple lesions showing peripheral hypointense rim and hypointense center, macro and microabscesses Yes Bone marrow edema, intraosseous cavities, destruction Yes NR 13 Laohawiriyakamol T et al. 2014 (40) Thailand 8 A- 4 E- 4 Central hyperreflective area surrounded by hypoechoic tissue with increased vascularity Multiple small discrete round-to-oval hyperintense lesions separated by hypointense rim and central hypointense dot Yes Bone marrow abnormality NR NR 14 Burfman T et al. 2015 (27) Israel 1 E NR NR NR Infiltrating destructive lesion of first metatarsal with bone remodelling Present (solid) NR 15 Martinez EI et al. 2016 (28) Spain 1 A Hypoechoic lesions with central hyperechoic foci Soft tissue mass with multiple discrete and conglomerate hyperintense lesions with central hypointense foci Yes 1. Lytic destruction with surrounding sclerosis- Snow melting pattern 2. Articular erosions NR Present (at second interphalangeal joint) 16 Neelakantan S et al. 2016 (41) India 1 E Multiple conglomerate hypoechoic lesions with hyperechoic center and diffusely increase Doppler signal Increased T2/ STIR signal of the subcutaneous and muscular planes with multiple conglomerate T2/ STIR hyperintense lesions with hypointense rim. Few of the lesions showed central hypointense foci. Yes Absent Absent Absent 17 Sidhu R et al. 2017 (25) India 1 E Multiple hypoechoic lesions with hyperechoic centers Multiple T2 hyperintense lesions with low signal rim and central hypointense foci Yes Moth- eaten pattern of bone destruction with sclerosis Present (aggressive) NR 18 Guerra Leal JD et al. 2018 (42) Mexico 6 A Multiple hypoechoic nodules with extensive soft tissue inflammation Inflammatory changes with soft tissue abscesses Yes Punched out lesions seen in 4 of 6 patients Present in 4 patients NR 19 Yadav T et al. 2019 (15) India 4 E Case 1 Multiple lesions with central hyperechoic foci and peripheral hypoechoic wall Multiple hyperintense lesions with hypointense foci Yes Absent Absent Absent Case 2 Multiple hypoechoic lesions with central hyperechoic foci Multiple hyperintense lesions with central hypointense dots Yes Absent Absent Absent Case 3 Multiple clustered lesions with peripheral hypoechogenicity and hyperechoic center Multiple hyperintense lesions with hypointense dots Yes Absent Absent Absent Case 4 Ill-defined lesions with central hyperechoic foci and peripheral hypoechoic wall Multiple hyperintense lesions with dot in circle sign in the soft tissue and bones Yes Multiple osteolytic lesions with diffuse sclerosis Present (aggressive) NR 20 Serfaty A et al. 2020 (23) Brazil 1 E NR NR NR Multiple bone cavities with permeative bone destruction and sclerosis Present (aggressive) Bony ankylosis of small joints of foot 21 Karrakchou B et al. 2020 (4) Morocco 1 E NR Multiple soft tissue collections Yes Absent Absent NR 22 Gameraddin M et al. 2020 (30) Sudan 60 A & E Multiple cavities and aggregated grains (E > A) Heterogeneous ehcotexture (E > A) Vascularity (E > A) NR NR NR NR 23 Sahu BK et al. 2021 (43) India 3 (Radiological features have been described in one case) E NR NR Yes NR NR NR 24 Jolu A et al. 2021 (44) France 1 A NR Intraosseous conglomerated foci and microabscesses within calcaneum NR Lytic bone cavities with sclerosis of calcaneum Present Absent 25 Tarafdar S et al. 2022 (24) India 7 (4 cases of pedal mycetoma) E Case 1 E NR Extensive soft tissue involvement Yes Punched out lytic lesions with diffuse sclerosis of bones Present NR Case 2 E NR Interarticular soft tissue showing increased PD FS signal Yes Punched out lytic areas Absent NR Case 3 E NR Soft tissue mass showing areas of diffusion restriction with homogeneous enhancement Yes Permeative bone destruction Present (aggressive) NR Case 4 E NR Serpinginous high signal mass infiltrating the soft tissue of foot Yes Marrow edema in metatarsal Absent NR 26 Hoogervorst LA et al. 2022 (29) Netherlands 1 (immunocompromised) E NR Multiple nodules in soft tissue and multiple intraosseous lesions Yes Absent Absent NR 27 Bentaleb D et al. 2022 (12) Morocco 2 A Case 1 Hyperreflective area surrounded by hypoechoic soft tissue showing increased vascularity Multiple small hyperintense lesions with peripheral fibrosis and central hypointense foci, infiltration of surrounding soft tissue Yes Joint effusion in metatarsophalangeal joint NR NR Case 2 Echogenic nodules with hypoechoic halo Multiple round to spherical hyperintense lesions with separated by hypointense tissue and few showing hypointense center, infiltration of plantar fascia and muscles Yes Bone marrow edema in metatarsals NR NR 28 Nabih OO et al. 2023 (14) Morocco 1 A NR Scattered and contiguous rounded T2 hyperintense lesions with hypointense border and central hpointense foci Yes Osteolysis of tarsals and metatarsals NR NR 29 Hailemariam T et al. 2023 (11) Ethiopia 2 E Case 1 Heterogeneous lesion containing multiple hypoechoic thick- walled lesions with small hyperechoic foci, increased vascularity in surrounding soft tissue NR Yes Well-defined coritcal erosions Present (Solid) Case 2 NR Multiple variable sized lesions involving soft tissue and bones, lesions were hyperintense with a central dot and peripheral hypointense rim Yes Permeative bone destruction Present (aggressive) NR 30 Present case India 1 A Infiltrative ill-defined heterogeneously hypoechoic soft tissue, multiple variable sized hypoechoic lesions with central hyperechoic foci and hyperechoic rim Ill-defined heterogeneous infiltrative soft tissue involving the subcutaneous tissue, muscles and bones with multiple variable sized lesions appearing hyperintense on STIR/ PD FS with hypointense rim and central hypointense foci Yes Moth eaten pattern of destruction with surrounding sclerosis and bone marrow edema Present (solid) Absent A- Actinomycetoma E- Eumycetoma NR- Not reported Table 2: Radiography- based staging system proposed by Abd El Bagi ME et al (31) Stage Radiographic feature Stage 0 No bone involvement Stage I Displacement or cortical scalloping Stage II Isolated periosteal reaction or reactive cortical sclerosis Stage III Solitary bone involvement Stage IV Longitudinal spread along single ray Stage V Horizontal spread but limited to forefoot, midfoot or hind foot Stage VI Multidirectional spread involving multiple rays and rows of bones Table 3: MRI- based mycetoma skin, muscle, bone (MSMB) grading system proposed by El Shamy ME et al (32) Score MRI Feature Skin and subcutaneous tissue 0 No skin or subcutaneous involvement 1 Obliteration of skin and fascial planes 2 Abscess formation 3 Formation of sinus tract without grains 4 Formation of sinus tract with grains Muscle 0 No muscle involvement 1 Muscle oedema 2 Formation of micro-abscess 3 Formation of macro-abscess Bone 0 No bone involvement 1 Bone oedema 2 Bone cavitation 3 Bone destruction Table 4: Common differential diagnoses for pedal mycetoma with distinguishing clinicoradiological features Feature Pedal mycetoma Diabetic foot Localized cellulitis Osteomyelitis Charcot arthropathy Venous thrombosis Tubercular arthropathy Vascular malformation Clinical Fever - +/- + + - +/- + - Pain - +/- + + - +/- +/- - Signs of inflammation + + + + - + + - Discharging sinuses + +/- - + - - +/- - Lymphadenopathy +/- + - +/- - - + - Presentation Subacute/ chronic Acute/ subacute Acute Chronic Chronic Acute Subacute/ chronic Subacute/ chronic Inflammatory Markers Normal Elevated Elevated Elevated Normal Normal Elevated/ normal Normal Radiological Soft tissue characteristics Ill-defined infiltrative, hypoechoic, T2/STIR hyperintense Soft tissue edema and heterogeneity Soft tissue edema and heterogeneity Soft tissue edema and heterogeneity Atrophy Edema Inflammatory changes Ill-defined/ well defined lesion, insinuating across tissue planes, phleboliths Associated collections +/- + + + - - +/- - Sinuses + +/- - + - - +/- - Bone involvement Moth eaten/ permeative destruction and sclerosis Permeative bone destruction, osteolysis, fragmentation and resorption Normal Sequestrum with surrounding sclerosis, involucrum Sclerosis, osteolysis, fragmentation, resorption, intraarticular loose bodies, dislocation Normal Periarticular osteopenia, joint space narrowing, peripheral erosion, rice bodies Venous- hypoplasia, scalloping, osteopenia Arterial- bone resorption, erosions Periosteal reaction Aggressive/ solid Aggressive/ solid Absent Aggressive Solid - Aggressive/ solid Solid Deformity +/- - - +/- + - +/- - Dot-in-circle sign + - - Mimic - - Mimic Mimic Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4358839","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":297953628,"identity":"47663aed-88b1-42f2-98ef-c7d68e160b43","order_by":0,"name":"Ebinesh A","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYDACCcYGIHmAGcIrsAESjI0HSNBikAbS0kBAC5iEqTE4jMLFCvilm9sefPhzh52f/+zDBx8MztutbT8MtKXGJhqXFsk5B9sNZ7Y9Y5ZsOG5sOMPgdvK2M4lALcfSchtwaDG4kdgmzdtwmNngYBubNA9Qi9kBoBbGhsM4tdiDtPz5c5jZ/jAb++8/BueSzc4/xK/FQAKohYENaAsbGxszg8EBO7MbBGyRuHOwTbK37TCzxBk2Zskeg+QEsxtAWxLw+IV/dvsziR9/Difz9x9j/PCjws7e7Hw6MOhqbHBqgYFkGCMRrDKBgHIQsIMx7IlQPApGwSgYBSMMAACuH2RHThVfIAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-8778-9902","institution":"Ebinesh A* (Corresponding author), Junior Consultant, Department of Radiodiagnosis, Sri Narayani Hospital \u0026 Research Centre, Sripuram, Vellore- 632055, Tamil Nadu, India. Email: [email protected]","correspondingAuthor":true,"prefix":"","firstName":"Ebinesh","middleName":"","lastName":"A","suffix":""}],"badges":[],"createdAt":"2024-05-02 11:22:43","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4358839/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4358839/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":56108800,"identity":"c82cf02b-e594-4113-9e49-d70e5f47c354","added_by":"auto","created_at":"2024-05-08 16:16:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":302878,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical photograph of the patient showing swelling of the foot\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical photograph of the patient (A and B) showing swelling of the foot with a discharging wound in the lateral aspect (A).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/177e22931c088c18272cac46.png"},{"id":56108799,"identity":"3bd73a40-03d7-4ed9-af73-0495653c8d34","added_by":"auto","created_at":"2024-05-08 16:16:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":437439,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUltrasonographic images of the foot\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGrey scale ultrasonographic images of the foot show infiltrative soft tissue with multiple discrete and conglomerate nodular lesions showing ‘dot-in-circle' appearance (white arrows in A and B). A linear hypoechoic sinus tract was also seen (orange arrow in C).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/51abe0109f36d838e82673c0.png"},{"id":56108804,"identity":"372d8450-ed07-4890-8a02-b42e01b7ea9c","added_by":"auto","created_at":"2024-05-08 16:16:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":255240,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMRI images of the foot\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSagittal STIR (A), sagittal T2 (B and C) and coronal PD FS (D and E) images show ill-defined infiltrative hyperintense soft tissue with variable sized nodular lesions (white arrows in A-C) with several showing ‘dot-in-circle' appearance (red arrows in D and E).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/5f83c88c90511db7b020b4c7.png"},{"id":56108801,"identity":"f745f0e9-4045-447d-87a6-1949a77b64a2","added_by":"auto","created_at":"2024-05-08 16:16:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":170589,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiological images showing various forms of bone involvement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReformatted computed tomographic (CT) images in bone window (A-D) show moth- eaten pattern of bone destruction (white arrows in A- C) involving the tarsals and metatarsals and solid periosteal reaction (red arrow in D). Coronal T1 (E) and STIR (F) images show loss of normal T1 hyperintensity of the bone marrow of the metatarsal with diffuse increase in STIR signal (blue arrows in E and F).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/8f03295152b62139a378180e.png"},{"id":56108802,"identity":"f8ca3440-c93b-41b8-acac-4c46b010e5bb","added_by":"auto","created_at":"2024-05-08 16:16:05","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":556638,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMicroscopic images of the histopathological sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMagnified (10x) image of H \u0026amp; E staining (A) shows focal colony of basophilic filamentous bacteria with peripheral Splendore- Hoeppli phenomenon. Magnified (10x) image of GMS histochemical staining (B) demonstrates positively highlighted (brown stain) filamentous bacteria.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/ff1ed50dadac5e60a4316b72.png"},{"id":56108803,"identity":"908529f1-74bc-4093-9632-fcd34d0955ff","added_by":"auto","created_at":"2024-05-08 16:16:05","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":179900,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic representation of the granuloma showing ‘dot-in-circle' appearance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGranuloma shows a central core comprising of the microbial elements (shaded in red) surrounded by granulation tissue (shaded in yellow) with a peripheral fibrotic rim (red solid line), giving the characteristic ‘dot-in-circle' appearance.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/69fa7fbfa4d5d49afb8a690a.png"},{"id":56108807,"identity":"4ef8e29b-3e30-4ea6-a343-446115f5468d","added_by":"auto","created_at":"2024-05-08 16:16:05","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":183829,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUltrasonographic appearance of the granuloma showing ‘dot-in-circle' appearance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGrey scale ultrasonographic image (A) with annotation (B) shows a lesion with central hyperechoic core (shaded in red) surrounded by hypoechoic granulation tissue (shaded in yellow) and a peripheral hyperechoic rim of fibrosis (solid red-yellow line).\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/9f32f28e816776f2760a59c2.png"},{"id":56108805,"identity":"e67e0c42-cb53-416e-b00a-36633d95b71a","added_by":"auto","created_at":"2024-05-08 16:16:05","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":129121,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMRI appearance of the granuloma showing ‘dot-in-circle' appearance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePD FS MRI image (A) with annotation (B) shows a well-defined lesion with a central hypointense dot (shaded in red) surrounded by hyperintense granulation tissue (shaded in yellow) and a peripheral hypointense fibrotic rim (solid red-yellow line).\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/73e74040ca810f887b394916.png"},{"id":56109476,"identity":"6e1e7b2d-e9a7-4006-9d05-e0154493dc03","added_by":"auto","created_at":"2024-05-08 16:24:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3599419,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4358839/v1/eff75205-5a22-4877-a418-49bcc7c4fed2.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eFrom a Radiologist’s Eye: a Case Report of Actinomycetoma of the Foot With Comprehensive Review of Literature\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTropical diseases include a panel of communicable and non-communicable diseases that are prevalent along and between the tropic of Cancer and tropic of Capricorn belt (1). This includes infectious diseases like cholera, Malaria, HIV/AIDS, tuberculosis, leishmaniases, onchocerciasis, filariasis, trypanosomiasis, rickettsioses, etc. \u0026nbsp;and non-communicable diseases such as malnourishment, hypertension, diabetes, chronic obstructive pulmonary disease, myocardial infarction and cerebrovascular accident (2). \u0026nbsp;Madura foot has been classified by the WHO as an endemic disease of the subtropical and tropical areas (3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMadura foot is a chronic destructive granulomatous infectious disease involving the skin and subcutaneous tissue. It commonly affects the limbs, specifically the foot and ankle. However, it can also involve the abdominal wall, chest wall or head and neck region. Mycetoma of the foot is the most common form and is termed as mycetoma pedis or pedal mycetoma. Based on the causative agent, mycetoma is classified as actinomycetoma (caused by actinomyces) or eumycetoma (caused by Fungi). Owing to the non-availability of any large-scale studies, the true incidence of mycetoma still remains uncertain. However, the proportions of actinomycotic and fungal aetiologies are approximately estimated as 60% and 40% respectively (4, 5).\u003c/p\u003e\n\u003cp\u003eIn this report, represent a case of actinomycetes, in a middle-aged female and review of existing literature with specific emphasis on multimodality diagnostic imaging.\u003c/p\u003e"},{"header":"Case Report","content":"\u003ch2\u003eClinical Details\u003c/h2\u003e\n\u003cp\u003eA female patient of 36 years from the eastern part of India presented with swelling of the right foot and a discharging wound since 6 months (Figure 1). Initially, it was diagnosed as chronic bacterial osteomyelitis, and she was unsuccessfully treated with multiple courses of enteral and parenteral antibiotics from local hospitals. Her hematological parameters were unremarkable except for reduced hemoglobin concentration (9 g/dl).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eRadiological Features\u003c/h2\u003e\n\u003cp\u003eIn line with the ongoing diagnosis, she was referred for an ultrasonography to detect and quantify localized collection, if any. Ultrasonography (USG) revealed infiltrative ill-defined hypoechoic soft tissue in the dorsum and sole of foot with inflamed adjacent fat. Multiple discrete and confluent nodular lesions, in solitary and clustered distribution were seen within the soft tissue (Figure 2). These nodular lesions showed a central hyperechoic focus surrounded by hypoechoic tissue with a peripheral hyperechoic rim, giving target/ do-in-circle appearance. A linear hypoechoic sinus tract was seen reaching up to the overlying skin surface.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor further evaluation, magnetic resonance imaging (MRI) was performed. MRI revealed nodular infiltrative soft tissue, involving the subcutaneous tissue and muscles of the sole and dorsum of foot. The soft tissue exhibited low signal intensity on T1 and heterogeneously high signal intensity on T2/ PD FS/ STIR. \u0026nbsp;Multiple variable sized well-defined nodular lesions were scattered within the soft tissue appearing hyperintense on T2/ STIR with a peripheral hypointense rim and central hypointense foci, representing dot-in-circle sign (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExtensive bone involvement was also seen (Figure 4). Moth- eaten pattern of bone destruction was seen involving the proximal ends of first, second and fourth metatarsals. Sclerosis of the adjacent bone was also seen. Solid periosteal reaction was seen along the second metatarsal. There was associated loss of normal T1 hyperintensity of the bone marrow with increase in PD FS/ STIR signal. Though the third and fifth metatarsals did not show obvious bone lysis or lesion, MRI revealed altered marrow signal intensity, representing involvement.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eHistopathology\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eFor confirmation of the diagnosis, a surface biopsy was performed. Histopathological examination with H\u0026amp;E staining revealed a focal colony of basophilic filamentous bacteria with peripheral Spleondore- Heoppli phenomenon. Filamentous bacteria stained positive on Grocott's methenamine silver (GMS) stain (Figure 5).\u003c/p\u003e\n\u003ch2\u003eManagement\u003c/h2\u003e\n\u003cp\u003eIn view of extensive bone involvement and local spread, an above knee amputation was planned. Patient was reluctant for the same and subsequently defaulted.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMadura foot was recognized as a disease entity by Gill in the year 1842 at Madurai, India and was later termed \u0026lsquo;mycetoma\u0026rsquo; by Carter in 1880 (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). It commonly affects those occupations that are in close contact with soil and vegetations such as farmers, cattle breeders, agricultural workers and poultry farmers. It usually involves parts of the body that are exposed to the soil like hands, feet and lower legs. Transdermal inoculation is the most common route of transmission, usually following trauma or penetrating injury (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIt is prevalent in patients between 20 to 40 years of age and demonstrates male predilection with a reported male-female ratio of 3.5: 1 (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). It is a sinister disease that painlessly spreads through the soft tissue to involve bones, rendering conservative management options futile. Clinically, it presents with a triad of features- painless foot swelling, multiple sinuses and discharging specific-colored grains (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). Though actinomycetoma and eumycetoma present with similar features, the former exhibits a rapid progressive course resulting in locally advanced and disseminated infection (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). Infection progresses in four stages (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). The first stage of the disease is incubation which can vary from a few weeks to years. Subsequently, the patients develop nonspecific features of local cellulitis like swelling and pain. As the pathogen proliferates in the subcutaneous plane, microabcesses with surrounding granulation tissue result in formation of subcutaneous nodules. As these nodules increase in size, they erupt the overlying skin surface forming discharging sinuses. Eventually, the disease extends into deeper tissue planes and involves bones causing significant soft tissue and osseous destruction. Deformity soon ensues destruction.\u003c/p\u003e\n\u003cp\u003eIn the advanced stages, diagnosis can be made readily based on classical clinical features. During the early indolent course of the disease, it is often misdiagnosed and unsuccessfully treated as common bacterial cellulitis. At the time of diagnosis, the disease is usually advanced with extensive soft tissue and bone involvement necessitating amputation. Hence, the challenge lies in early diagnosis of the disease.\u003c/p\u003e\n\u003cp\u003eRadiological investigations, especially ultrasonography (USG) and magnetic resonance imaging (MRI) are indispensable modalities tools for early diagnosis. Plain radiographs can be normal in the early stage of disease but can demonstrate bone involvement and soft tissue thickening. However, computed tomography (CT) helps in better characterization of the pattern of bone involvement, periosteal reaction, presence of osteoporosis and bone destruction (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e). Magnetic resonance imaging (MRI) is the imaging modality of choice aiding in excellent characterization of the soft tissue, associated extensions and infiltration, bone involvement and bone marrow edema. It also plays an indispensable role in pretherapeutic staging, evaluation of associated complications and therapeutic response assessment. Bone scintigraphy is another valuable tool for assessment of therapeutic response (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe spectrum of radiological features comprises of various patterns of soft tissue and bone involvement. USG and MRI are the preferred tools for soft tissue characterization. On USG, it presents as an ill- defined hypoechoic infiltrative mass. Few authors have described increased color flow and Doppler signals within soft tissue which can be secondary to inflammation (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). On MRI, the soft tissue appears hyperintense on T2, PD FS and STIR sequences. It predominantly involves the subcutaneous tissue but frequently infiltrates the muscles and deeper soft tissue due to its aggressive nature (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e), as observed in our case. The presence of \u0026lsquo;dot-in-circle\u0026apos; sign has been described as a specific hallmark for pedal mycetoma (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e). It has been described in cases of both eumycetoma and actinomycetoma. The basis of \u0026lsquo;dot-in-circle\u0026apos; sign depends on the pathological organization of the granuloma which comprises of a central core of microbial elements (fungal hyphae or filamentous bacteria) surrounded by granulation tissue and chronic inflammatory infiltrate with a peripheral rim of fibrosis (Fig. \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e) (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). It was first described by Sarris I et al in 2003 (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). However, the earlier available case reports also describe similar findings (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). On USG, it appears as a hypoechoic lesion with a central hyperechoic core and peripheral hypoechoic rim (Fig. \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e). On MRI, this sign is best described on T2 FS, PD FS and STIR sequences in which these lesions appear hyperintense with a central hypointense focus and a peripheral hypointense rim (Fig. \u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e). T1 FS post contrast images have also been described to depict \u0026lsquo;dot-in-circle\u0026apos; sign but demonstrate no obvious advantage over non contrast sequences (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). However, post contrast images can additionally demonstrate the actual extent of soft tissue infiltration, associated collections, disease activity and subtle bone involvement. Diffusion weighted imaging (DWI) can aid in assessment of therapeutic response. Though few authors have not specifically reported \u0026lsquo;dot-in-circle\u0026apos; sign, Jimenez AL et al (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) reported the absence of the same in a case of eumycetoma which was initially misdiagnosed as synovial sarcoma. The presence of sinus tracts, hypoechoic on USG and hyperintense on T2/ STIR is another feature of mycetoma.\u003c/p\u003e\n\u003cp\u003eBone involvement includes bone destruction, sclerosis, periosteal reaction and resultant deformities. As a general observation, most authors have reported aggressive patterns of bone destruction of which moth- eaten pattern and permeative type are the most common (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). Aggressive forms of periosteal reaction such as interrupted, lamellated and spiculated patterns have been described as frequent associations (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). As in our case, few authors have also reported nonaggressive solid form of periosteal reaction (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). Martinez EI et al (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) described \u0026lsquo;snow melting\u0026rsquo; pattern of bone involvement characterized by lytic bone destruction with surrounding florid dense sclerosis. The presence of bone marrow edema without obvious cortical involvement or bone destruction can represent early involvement. Hoogervorst LA et al (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) reported noncontiguous disseminated small hypointense lesions scattered within the tibial bone marrow in an immunocompromised patient without any bone involvement. Advanced long term disease results in extensive osteolysis, sclerosis and bony ankylosis (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). The salient radiological features that have been described in the earlier literature are summarized in table 1.\u003c/p\u003e\n\u003cp\u003eDistinctive patterns of bone involvement in actinomycetoma and eumycetoma have been observed (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). Eumycetoma is associated with larger (usually\u0026thinsp;\u0026gt;\u0026thinsp;1 cm in size) intraosseous cavities while Actinomycetoma causes moth- eaten pattern of bone destruction i.e., multiple punctate well-defined cavities. Gameraddin M et al (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) studied the differential sonographic and Doppler characteristics of eumycetoma and actinomycetoma. They reported that eumycetoma was associated with multiple aggregated grains, more heterogeneous echotexture and higher vascularity in comparison to actinomycetoma.\u003c/p\u003e\n\u003cp\u003eRadiological staging of the disease is imperative for planning the treatment and patient counseling. In 2003, Abd El Bagi ME (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) devised a radiography- based system for staging bone involvement in pedal mycetoma (Table\u0026nbsp;2). Subsequently in 2013, El Shamy ME et al (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) proposed a detailed MRI- based mycetoma skin, muscle, bone (MSMB) grading system (Table\u0026nbsp;3) which comprises of three subscores- skin (scores 0\u0026ndash;4), muscle (0\u0026ndash;3) and bone (0\u0026ndash;3). Out of a total score of 10, a score of 1\u0026ndash;3 is considered mild, 4\u0026ndash;7 is considered moderate and 8\u0026ndash;10 is considered severe.\u003c/p\u003e\n\u003cp\u003eImaging also aids in evaluating the therapeutic response in patients on conservative management (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e). Radiological features of healing are remodeling and sclerosis of the active edges of erosions, ossification of bone cavities and solid periosteal reaction, generalized bone sclerosis, resolution of bone marrow signal alteration, disappearance of granulomata (showing \u0026lsquo;dot-in-circle\u0026apos; appearance), reduced heterogeneity of soft tissue enhancement, normalization of diffusion restriction and normalization of increased uptake on bone scintigraphy.\u003c/p\u003e\n\u003cp\u003eDue to painless and quiescent progression of the disease, numerous patients present with complications even at the time of initial diagnosis. Complications include periostitis, osteomyelitis, arthritis, bone destruction resulting in deformity, secondary bacterial infection, bacteremia and septicemia (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eDifferential diagnoses include diabetic foot, localized bacterial cellulitis, osteomyelitis, Charcot arthropathy, venous thrombosis, tuberculosis and vascular tumors and malformations. Among these conditions, soft tissue collection with bone fragments in osteomyelitis, rice bodies in tuberculosis and phleboliths in vascular malformations can mimic \u0026lsquo;dot-in-circle\u0026apos; appearance. Clinicoradiological features that aid in differentiating these conditions are enumerated in table 4.\u003c/p\u003e\n\u003cp\u003eTreatment of pedal mycetoma depends on the causative pathogen and stage of the disease. Actinomycetoma is treated with a combined regimen of antimicrobial agents including co-trimoxazole, dapsone, amikacin and tetracycline (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e). Drug therapy of eumycetoma involves azole derivatives (itraconazole, voriconazole, fluconazole and miconazole) and co-trimoxazole. Surgical debulking of the disease might be necessary in case of larger lesions (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e). Age\u0026thinsp;\u0026gt;\u0026thinsp;59 years, lesion of size\u0026thinsp;\u0026gt;\u0026thinsp;10 cm, duration of disease\u0026thinsp;\u0026gt;\u0026thinsp;5 years and positive family history are predictors of recurrence following surgical debulking or excision (\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e). Locally advanced disease with bone involvement might require amputation of the limb.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePedal mycetoma is a tropical granulomatous disease involving the soft tissue of the foot, caused by actinomyces or fungi. Radiological investigations form the main stay of diagnostic work up. USG and MRI are the preferred modalities for evaluation. MRI is an excellent tool for soft tissue characterization, evaluation of spread, bone involvement, staging and therapeutic response assessment. The presence of \u0026lsquo;dot-in-circle' sign is pathognomonic. Owing to its quiescent progression, the challenge lies in early diagnosis of the disease, underscoring the significance of diagnostic imaging. Early diagnosis also warrants good therapeutic outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIV/AIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman immunodeficiency virus/ Acquired immunodeficiency syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUltrasonography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePD FS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProton density fat saturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT2 FS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eT2 fat saturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT1 FS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eT2 fat saturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTIR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eShort tau inversion recovery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDWI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiffusion weighted imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eH\u0026amp;E\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHematoxylin \u0026amp; Eosin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGrocott's methenamine silver\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMSMB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMycetoma skin, muscle, bone grading\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"DECLARATIONS","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from patients to publish the case and use their radiological images involved in the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study involving a human participant were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eZumla A, Ustianowski A. Tropical diseases: definition, geographic distribution, transmission, and classification. Infect Dis Clin North Am. 2012; 26: 195-205.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCook G.C., Zumla A., editors. Manson\u0026apos;s tropical diseases. 22nd edition. Saunders; London: 2009. p. 1830.\u003c/li\u003e\n \u003cli\u003ePierre- Jerome C, Kettner WN. The essentials of Charcot neuropathy. Elsevier; Amsterdam: 2022. P. 223-59.\u003c/li\u003e\n \u003cli\u003eKarrakchou B, Boubnane I, Senouci K et al. Madurella mycetomatis infection of the foot: a case report of a neglected tropical disease in a non-endemic region. BMC Dermatol. 2020; 20: 1.\u003c/li\u003e\n \u003cli\u003eWelsh O, Vera-Cabrera L, Salinas-Carmona MC.\u0026nbsp;Mycetoma. Clin Dermatol. 2007; 25: 195-202.\u003c/li\u003e\n \u003cli\u003eCarroll DS. Mycetoma pedis. Radiology. 1949; 53: 81\u0026ndash;4.\u003c/li\u003e\n \u003cli\u003eCherian RS, Betty M, Manipadam MT, et al. The \u0026ldquo;dot-in-circle\u0026rdquo; sign\u0026mdash;a characteristic MRI finding in mycetoma foot: a report of three cases. Br J Radiol. 2009; 82: 662\u0026ndash;5.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFahal AH, Shaheen S, Jones DHA. The orthopaedic aspects of mycetoma. Bone Joint J. 2014; 96-B: 420\u0026ndash;5.\u003c/li\u003e\n \u003cli\u003eVenkatswami S, Sankarasubramanian A, Subramanyam S. The madura foot: looking deep. Int J Low Extrem Wounds. 2012; 11: 31-42.\u003c/li\u003e\n \u003cli\u003eCzechowski J, Nork M, Haas D et al. MR and other imaging methods in the investigation of mycetomas. Acta Radiologica. 2001; 42: 24-6.\u003c/li\u003e\n \u003cli\u003eHailemariam T, Tamiru R, Manyazewal T et al. Madura foot and a continued diagnostic enigma: Dot-in-circle sign on magnetic resonance imaging and ultrasound. IDCases. 2023; 33: e01857.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBentaleb D, Mahdar I, Noureddine L et al. Diagnostic imaging of foot mycetomas: A report on two cases. Radiol Case Rep. 2022; 17: 1817- 23.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCherian RS, Betty M, Manipadam MT et al. The \u0026quot;dot-in-circle\u0026quot; sign -- a characteristic MRI finding in mycetoma foot: a report of three cases. Br J Radiol. 2009; 82: 662-5.\u003c/li\u003e\n \u003cli\u003eNabih OO, Bouardi EN, Haloua M et al. Case report: The dot in circle sign: A pathognomonic MRI sign of madura foot. Radiol Case Rep. 2023; 18: 3849- 52.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYadav T, Meena VK, Shaikh M et al. Clinico-radiological-pathological correlation in eumycetoma spectrum: Case series. North Clin Istanb. 2019; 7: 400-6.\u003c/li\u003e\n \u003cli\u003eSarris I, Berendt AR, Athanasous N, et al.\u0026nbsp;MRI of mycetoma of the foot: two cases demonstrating the dot-in-circle sign. Skeletal Radiol. 2003; 32: 179-83.\u003c/li\u003e\n \u003cli\u003eFahal AH, Sheik HE, Homeida MM et al. Ultrasonographic imaging of mycetoma. Br J Surg. 1997; 84: 1120-2.\u003c/li\u003e\n \u003cli\u003eIspoglou SS, Zormpala A, Androulaki A et al.\u0026nbsp;Madura foot due to Actinomadura madurae: imaging appearance. J Clin Imaging. 2003; 27: 233-35.\u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJimenez AL, Salvo NL. Mycetoma or synovial sarcoma?\u0026nbsp;A case report with review of the literature. J Foot Ankle Surg. 2011; 50: 569-76.\u003c/li\u003e\n \u003cli\u003eLewall DB, Ofole S, Bendl B. Mycetoma. Skeletal Radiol. 1985;14: 257\u0026ndash;62.\u003c/li\u003e\n \u003cli\u003eJain V, Makwana EG, Bahri N et al. The \u0026ldquo;Dot in Circle\u0026rdquo; Sign on MRI in Maduramycosis: A Characteristic Finding. J Clin Imaging Sci. 2012; 2: 66.\u003c/li\u003e\n \u003cli\u003eAsly M, Rafaoui A, Bouyermane H, Hakam K, Moustamsik B, Lmidmani F, Rafai M, Largab A, Elfatimi A. Mycetoma (Madura foot): A case report. Ann Phys Rehabil Med. 2010; 53: 650-4.\u003c/li\u003e\n \u003cli\u003eSerfaty A, Righetti Vieira Ferreira de Ara\u0026uacute;jo A, Severo A et al.\u0026nbsp;Long-term radiographic features of Madura foot. Joint Bone Spine. 2020; 87:167.\u003c/li\u003e\n \u003cli\u003eTarafdar S, Kanimozhi P, Sabarish S et al. Magnetic Resonance Imaging in the Diagnosis of Mycetoma with Equivocal Clinical and Laboratory Features. Indian J Dermatol. 2022; 67: 459-463.\u003c/li\u003e\n \u003cli\u003eSidhu R, Patel P, Parikh U et al. Madura foot. Eurorad. 2017; 14374.\u003c/li\u003e\n \u003cli\u003eElmaataoui A, \u0026nbsp;Elmoustachi A, Aoufi S et al.\u0026nbsp;Eumycetoma due to Madurella mycetomatis from two cases of black grain mycetoma in Morocco. J Mycol Med. 2011; 21: 281- 84.\u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBrufman T, Ben-Ami R, Mizrahi M et al. Mycetoma of the Foot Caused by Madurella Mycetomatis in Immigrants from Sudan. Isr Med Assoc J. 2015; 17: 418-20.\u003c/li\u003e\n \u003cli\u003eMartinez EI, Fuentes RC, Sanchez MA et al.\u0026nbsp;Mycetoma foot. Eurorad. 2016; 13444.\u003c/li\u003e\n \u003cli\u003eHoogervorst LA, Op de Coul LS, Ray A, et al. Mycetoma caused by Madurella mycetomatis in immunocompromised patients - a case report and systematic literature review. J Bone Jt Infect. 2022; 7: 241-8.\u003c/li\u003e\n \u003cli\u003eGameraddin M, Gareeballah A, Mokhtar S, M Abuzaid M, Alhazmi F, Ali Hamad H. Characterization of Foot Mycetoma Using Sonography and Color Doppler Imaging. Pak J Biol Sci. 2020; 23:968-972.\u003c/li\u003e\n \u003cli\u003eAbd El Bagi ME. New radiographic classification of bone involvement in pedal mycetoma. AJR Am J Roentgenol. 2003; 180: 665-8.\u003c/li\u003e\n \u003cli\u003eEl Shamy ME, Fahal AH, Shakir MY et al. New MRI grading system for the diagnosis and management of mycetoma. Trans R Soc Trop Med Hyg. 2012; 106: 738-42.\u003c/li\u003e\n \u003cli\u003eAgarwal P, Jagati A, Rathod SP et al. Clinical Features of Mycetoma and the Appropriate Treatment Options. Res Rep Trop Med. 2021; 12: 173-9.\u003c/li\u003e\n \u003cli\u003eGrover S, Roy P, Singh G. MADURA FOOT. Med J Armed Forces India. 2001; 57: 163-4.\u003c/li\u003e\n \u003cli\u003eRelhan V, Mahajan K, Agarwal P et al. Mycetoma: An Update. Indian J Dermatol. 2017; 62: 332-40.\u003c/li\u003e\n \u003cli\u003eSalim AO, Mwita CC, Gwer S. Treatment of Madura foot: a systematic review. JBI Database System Rev Implement Rep. 2018; 16: 1519-36. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eScolding P, Fahal A, Yotsu RR. Drug therapy for Mycetoma. Cochrane Database Syst Rev. 2018; 2018: CD013082.\u003c/li\u003e\n \u003cli\u003eWadal A, Elhassan TA, Zein HA et al. Predictors of Post-operative Mycetoma Recurrence Using Machine-Learning Algorithms: The Mycetoma Research Center Experience. PLoS Negl Trop Dis. 2016;10: e0005007.\u003c/li\u003e\n \u003cli\u003eSalamon ML, Lee JH, Pinney SJ. Madura foot (madurella mycetoma) presenting as a plantar fibroma: a case report. Foot Ankle Int. 2006; 27: 212-5.\u003c/li\u003e\n \u003cli\u003eLaohawiriyakamol T, Tanutit P, Kanjanapradit K et al. The \u0026quot;dot-in-circle\u0026quot; sign in musculoskeletal mycetoma on magnetic resonance imaging and ultrasonography. Springerplus. 2014; 3: 671.\u003c/li\u003e\n \u003cli\u003eNeelakantan S, Babu AAS, Anandarajan. \u0026nbsp;R\u0026lsquo;Dot in circle sign\u0026rsquo;: a characteristic finding in ultrasound and MR imaging of soft tissue mycetomas. Case Reports. 2016; 2016: bcr2016216502.\u003c/li\u003e\n \u003cli\u003eGuerra-Leal JD, Medrano-Dan\u0026eacute;s LA, Montemayor-Martinez A et al.\u0026nbsp;The importance of diagnostic imaging of mycetoma in the foot. Int J Dermatol. 2019; 58: 600-604.\u003c/li\u003e\n \u003cli\u003eSahu BK, Nag HL. An Illustrative Report of Three Cases of Madura Foot with Diagnostic and Treatment Features. J Orthop Case Rep. 2021; 11: 74-78.\u003c/li\u003e\n \u003cli\u003eJolu A, Rosine N. Madura foot: Actinomycetoma of the calcaneum. Joint Bone Spine. 2021; 88: 105170.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Salient radiological features of Pedal mycetoma described earlier in the literature\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"960\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eS. No.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.166666666666668%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSoft tissue characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresence of Dot-in-circle sign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePattern of bone involvement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriosteal reaction\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeformity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.57142857142857%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUSG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.42857142857143%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eLeewall DB et al. 1985 (20)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eSaudi Arabia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003e19- A\u003c/p\u003e\n \u003cp\u003e11- E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eSclerosis, cortical erosions, intraosseous cavities, moth- eaten pattern, osteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (laminated/ spiculated/ bizarre)- 67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eFahal AH et al. 1997 (17)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eSudan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eHyperreflective grains surrounded by single or multiple thick -walled cavities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eCzechowski J et al. 2001 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eUAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003e13- A\u003c/p\u003e\n \u003cp\u003e7- E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eLoss of normal signal intensity of the soft tissue with increased T2 signal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eBone marrow abnormalities in 15 patients\u003c/p\u003e\n \u003cp\u003eBone destruction, erosions and coarsening of trabeculae\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eIspoglou SS et al. 2003 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eGreece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eAltered signal intensity of the affected soft tissue and bones, T1/ T2 hypointense ovoid lesions within the affected bones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMottled destruction of tarsals and metatarsals, sclerosis and bone marrow involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eSarris I et al. 2003 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eReported in UK\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eHypoechoic lesion with hyperechoic foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eHyperintense lesions separated by hypointense stroma on STIR with central low signal intensity evident on T1FS post contrast images.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eNigeria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eFollow up MRI- nonspecific inflammation with T2 hyperintense lesion showing central hypointensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eSalamon LM et al. 2006 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eHyperintense subcutaneous lesion with internal hypointense foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eCherian RS et al. 2008 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eConglomerate areas of multiple discrete, small round hyperintense lesions with peripheral low signal rim and central dot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eInfiltrative lesion involving the subcutaneous and muscular planes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eExtensive altered signal intensity involving the tarsals and soft tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eChronic osteomyelitis of tarsals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eAsly M et al. 2010 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMorocco\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eBone resorpiton and permeative bone destruction diffusely involving the tarsals, metatarsals and phalanges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eJimenez AL et al. 2011 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eMultiloculated well defined subcutaneous mass at the dorsum of distal foot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eElmaataoui A et al. 2011 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMorocco\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eGeographic bone ill-defined bone destruction with sclerosis \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (solid)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eJain V et al. 2012 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eExtensive soft tissue and osseous inflammation, multiple discrete and confluent spherical lesions with hypointense rim, few showing central hypointense focus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMoth eaten type of bone destruction with articular erosions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eEl Shamy EM et al. 2012 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eSudan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e42 (foot involvement in 25 patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA- 24\u003c/p\u003e\n \u003cp\u003eE- 18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eIll-defined infiltrative soft tissue with multiple lesions showing peripheral hypointense rim and hypointense center, macro and microabscesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eBone marrow edema, intraosseous cavities, destruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eLaohawiriyakamol T et al. 2014 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eThailand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA- 4\u003c/p\u003e\n \u003cp\u003eE- 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eCentral hyperreflective area surrounded by hypoechoic tissue with increased vascularity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple small discrete round-to-oval hyperintense lesions separated by hypointense rim and central hypointense dot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eBone marrow abnormality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eBurfman T et al. 2015 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIsrael\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eInfiltrating destructive lesion of first metatarsal with bone remodelling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (solid)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eMartinez EI et al. 2016 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eSpain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eHypoechoic lesions with central hyperechoic foci\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eSoft tissue mass with multiple discrete and conglomerate hyperintense lesions with central hypointense foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e1. Lytic destruction with surrounding sclerosis- Snow melting pattern\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2. Articular erosions\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (at second interphalangeal joint)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNeelakantan S et al. 2016 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple conglomerate hypoechoic lesions with hyperechoic center and diffusely increase Doppler signal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eIncreased T2/ STIR signal of the subcutaneous and muscular planes with multiple conglomerate T2/ STIR hyperintense lesions with hypointense rim. Few of the lesions showed central hypointense foci.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eSidhu R et al. 2017 \u0026nbsp;(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple hypoechoic lesions with hyperechoic centers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple T2 hyperintense lesions with low signal rim and central hypointense foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMoth- eaten pattern of bone destruction with sclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (aggressive)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eGuerra Leal JD et al. 2018 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMexico\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple hypoechoic nodules with extensive soft tissue inflammation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eInflammatory changes with soft tissue abscesses\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003ePunched out lesions seen in 4 of 6 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent in 4 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eYadav T et al. 2019 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple lesions with central hyperechoic foci and peripheral hypoechoic wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple hyperintense lesions with hypointense foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple hypoechoic lesions with central hyperechoic foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple hyperintense lesions with central hypointense dots\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple clustered lesions with peripheral hypoechogenicity and hyperechoic center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple hyperintense lesions with hypointense dots\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eIll-defined lesions with central hyperechoic foci and peripheral hypoechoic wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple hyperintense lesions with dot in circle sign in the soft tissue and bones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple osteolytic lesions with diffuse sclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (aggressive)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eSerfaty A et al.\u003c/p\u003e\n \u003cp\u003e2020 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple bone cavities with permeative bone destruction and sclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (aggressive)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eBony ankylosis of small joints of foot\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eKarrakchou B et al. 2020 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMorocco\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple soft tissue collections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eGameraddin M et al. 2020 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eSudan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA \u0026amp; E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple cavities and aggregated grains (E \u0026gt; A)\u003c/p\u003e\n \u003cp\u003eHeterogeneous ehcotexture (E \u0026gt; A)\u003c/p\u003e\n \u003cp\u003eVascularity (E \u0026gt; A)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eSahu BK et al. 2021 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e3 (Radiological features have been described in one case)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eJolu A et al. 2021 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eIntraosseous conglomerated foci and microabscesses within calcaneum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eLytic bone cavities with sclerosis of calcaneum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eTarafdar S et al. 2022 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e7 (4 cases of pedal mycetoma)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eExtensive soft tissue involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003ePunched out lytic lesions with diffuse sclerosis of bones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eInterarticular soft tissue showing increased PD FS signal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003ePunched out lytic areas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eSoft tissue mass showing areas of diffusion restriction with homogeneous enhancement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003ePermeative bone destruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (aggressive)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eSerpinginous high signal mass infiltrating the soft tissue of foot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eMarrow edema in metatarsal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eHoogervorst LA et al. 2022 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNetherlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1 (immunocompromised)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple nodules in soft tissue and multiple intraosseous lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eBentaleb D et al. 2022 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMorocco\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eHyperreflective area surrounded by hypoechoic soft tissue showing increased vascularity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple small hyperintense lesions with peripheral fibrosis and central hypointense foci, infiltration of surrounding soft tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eJoint effusion in metatarsophalangeal joint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eEchogenic nodules with hypoechoic halo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple round to spherical hyperintense lesions with separated by hypointense tissue and few showing hypointense center, infiltration of plantar fascia and muscles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eBone marrow edema in metatarsals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNabih OO et al. 2023 \u0026nbsp;(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMorocco\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eScattered and contiguous rounded T2 hyperintense lesions with hypointense border and central hpointense foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eOsteolysis of tarsals and metatarsals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eHailemariam T et al. 2023 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eEthiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eHeterogeneous lesion containing multiple hypoechoic thick- walled lesions with small hyperechoic foci, increased vascularity in surrounding soft tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003eWell-defined coritcal erosions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (Solid)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.956521739130435%\" valign=\"top\"\u003e\n \u003cp\u003eCase 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.369565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.869565217391305%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26086956521739%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.17391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eMultiple variable sized lesions involving soft tissue and bones, lesions were hyperintense with a central dot and peripheral hypointense rim\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.717391304347826%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.91304347826087%\" valign=\"top\"\u003e\n \u003cp\u003ePermeative bone destruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (aggressive)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.782608695652174%\" valign=\"top\"\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.166666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\" valign=\"top\"\u003e\n \u003cp\u003ePresent case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.020833333333334%\" valign=\"top\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.625%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.708333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eInfiltrative ill-defined heterogeneously hypoechoic soft tissue, multiple variable sized hypoechoic lesions with central hyperechoic foci and hyperechoic rim\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.458333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eIll-defined heterogeneous infiltrative soft tissue involving the subcutaneous tissue, muscles and bones with multiple variable sized lesions appearing hyperintense on STIR/ PD FS with hypointense rim and central hypointense foci\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.395833333333333%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eMoth eaten pattern of destruction with surrounding sclerosis and bone marrow edema\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.854166666666666%\" valign=\"top\"\u003e\n \u003cp\u003ePresent (solid)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;A- Actinomycetoma\u003c/p\u003e\n\u003cp\u003eE- Eumycetoma\u003c/p\u003e\n\u003cp\u003eNR- Not reported\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Radiography- based staging system proposed by Abd El Bagi ME et al (31)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiographic feature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003eStage 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003eNo bone involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003eStage I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003eDisplacement or cortical scalloping\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003eStage II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003eIsolated periosteal reaction or reactive cortical sclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003eStage III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003eSolitary bone involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003eStage IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003eLongitudinal spread along single ray\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003eStage V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003eHorizontal spread but limited to forefoot, midfoot or hind foot\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.58856345885635%\" valign=\"top\"\u003e\n \u003cp\u003eStage VI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.41143654114366%\" valign=\"top\"\u003e\n \u003cp\u003eMultidirectional spread involving multiple rays and rows of bones\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 3: MRI- based mycetoma skin, muscle, bone (MSMB) grading system proposed by El Shamy ME et al (32)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMRI Feature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSkin and subcutaneous tissue\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eNo skin or subcutaneous involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eObliteration of skin and fascial planes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eAbscess formation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eFormation of sinus tract without grains\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eFormation of sinus tract with grains\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMuscle\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eNo muscle involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eMuscle oedema\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eFormation of micro-abscess\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eFormation of macro-abscess\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBone\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eNo bone involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eBone oedema\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eBone cavitation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.04973357015986%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.95026642984014%\" valign=\"top\"\u003e\n \u003cp\u003eBone destruction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Common differential diagnoses for pedal mycetoma with distinguishing clinicoradiological features\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeature\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePedal mycetoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiabetic foot\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocalized cellulitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOsteomyelitis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharcot arthropathy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVenous thrombosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTubercular arthropathy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVascular malformation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eFever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSigns of inflammation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eDischarging sinuses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eLymphadenopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003ePresentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSubacute/ chronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAcute/ subacute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAcute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eChronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eChronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAcute\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSubacute/ chronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSubacute/ chronic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eInflammatory Markers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eElevated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eElevated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eElevated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eElevated/ normal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRadiological\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSoft tissue characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eIll-defined infiltrative, hypoechoic, T2/STIR hyperintense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSoft tissue edema and heterogeneity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSoft tissue edema and heterogeneity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSoft tissue edema and heterogeneity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAtrophy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eEdema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eInflammatory changes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eIll-defined/ well defined lesion, insinuating across tissue planes, phleboliths\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAssociated collections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSinuses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eBone involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eMoth eaten/ permeative destruction and sclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003ePermeative bone destruction, osteolysis, fragmentation and resorption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSequestrum with surrounding sclerosis, involucrum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSclerosis, osteolysis, fragmentation, resorption, intraarticular loose bodies, dislocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003ePeriarticular osteopenia, joint space narrowing, peripheral erosion, rice bodies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eVenous- hypoplasia, scalloping, osteopenia\u003c/p\u003e\n \u003cp\u003eArterial- bone resorption, erosions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003ePeriosteal reaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAggressive/ solid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAggressive/ solid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAggressive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSolid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eAggressive/ solid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eSolid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eDeformity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+/-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eDot-in-circle sign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eMimic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eMimic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eMimic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pedal mycetoma, Madura foot, Actinomycetoma, Dot-in-circle, Case report","lastPublishedDoi":"10.21203/rs.3.rs-4358839/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4358839/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTropical diseases comprise of an array of communicable and non-communicable diseases that prevail in the tropical belt. Madura foot, classified as a tropical disease by WHO, is a chronic granulomatous disease that predominantly involves the skin and subcutaneous tissue, commonly affecting the lower limbs. We present a case of actinomycetoma with extensive review of the existing literature, focusing on diagnostic imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eA 36-year-old female from eastern India presented with a six-month history of right foot swelling and a discharging wound. She was unsuccessfully treated with multiple courses of antibiotics in local hospitals. Upon referral, radiological investigations were performed for further evaluation. USG showed infiltrative hypoechoic soft tissue with nodular lesions showing targetoid appearance. MRI revealed infiltrative soft tissue with variable sized nodular lesion showing characteristic ‘dot-in-circle' appearance, prompting the diagnosis of pedal mycetoma. Actinomycetoma was confirmed on biopsy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003ePedal mycetoma presents significant diagnostic and therapeutic challenges owing to its insidious progression and delayed diagnosis. Radiological imaging, particularly MRI, plays a pivotal role in diagnosis and staging of the disease, enabling detailed evaluation of soft tissue and bone involvement. The ‘dot-in-circle' sign observed on imaging is pathognomic and aids in accurate diagnosis. Early diagnosis facilitated by diagnostic imaging warrants improved therapeutic outcomes.\u003c/p\u003e","manuscriptTitle":"From a Radiologist’s Eye: a Case Report of Actinomycetoma of the Foot With Comprehensive Review of Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-08 16:16:00","doi":"10.21203/rs.3.rs-4358839/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5e7e3b4-db71-42eb-a054-dd0859aa03a2","owner":[],"postedDate":"May 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31650587,"name":"Infectious Diseases"},{"id":31650588,"name":"Nuclear Medicine \u0026 Medical Imaging"},{"id":31650589,"name":"Orthopedics"}],"tags":[],"updatedAt":"2024-07-09T03:51:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-08 16:16:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4358839","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4358839","identity":"rs-4358839","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}