Case 249: Intramuscular Mycetoma

History A 21-year-old man presented with swelling of the medial aspect of the left thigh of 1-month duration. There was no history of fever or penetrating injury in the left thigh. The patient had undergone renal transplantation 7 years earlier and had been taking immunosuppressants since transplantation. He had undergone two surgeries at the same site in the medial aspect of the left thigh in the past 3 years for a similar problem. At physical examination, there was swelling in the medial aspect of the left thigh, with mild tenderness. A surgical scar was noted anterior to the swelling ( Fig 1 ). No redness or discharging sinus was present. Laboratory results were as follows: hemoglobin level, 11.3 g/dL (normal range, 13.8-17.2 g/dL); white blood cell count, 9.7 × 10 9 /L (normal range, [4-11] × 10 9 /L); neutrophil, 75% (normal range, 48%-77%); lymphocyte, 22% (normal range, 10%-24%); eosinophil, 1% (normal range, 0.3%- 7%); monocyte, 1% (normal range, 0.6%-10%); serum creatinine level, 1.3 mg/dL (114.9 μmol/L) (normal range, 0.5-1.6 mg/dL [44.2-141.4 μmol/L]); and serum glucose (random) level, 82 mg/dL (4.5 mmol/L) (normal range, 79-140 mg/dL [4.4-7.8 mmol/L]). Radiography of the left thigh showed soft-tissue swelling in the medial aspect of the left thigh, without underlying bone involvement (not shown). Ultrasonography (US) and magnetic resonance (MR) imaging of the left thigh were performed. [Figure: see text].