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We report on a 60-year-old housewife who presented to the Mycetoma Research Centre (MRC) at the University of Khartoum on the 7 December 2016 with a 30-year history of chest wall eumycetoma due to Madurella mycetomatis. Two months prior to presentation to the MRC, a discharging sinus in the left lateral side of the chest wall was noted by the patient. The discharge was purulent and contained black grains. Just before presentation, air leak from the sinus was noted and she developed general weakness and deterioration. The patient was noncompliant with ketoconazole therapy for eumycetoma and has had 3 previous surgical excisions of her chest wall lesion; the first one was in 1991, the second one was in 1995, and the third excision was done in 2002. However, she ceased treatment and follow up in 2002. The patient has had diabetes mellitus for 14 years and hypertension for 1 year. She has various diabetic microvascular complications, diabetic nephropathy, and diabetic septic foot, leading to left above-knee amputation in 2015, and she later developed right gangrenous middle and fourth toes. Her drug history includes insulin 10/5 units, furosemide 40 mg, aspirin 81 mg, atorvastatin 20 mg, and amlodipine 10 mg per day. She has had multiple hospital admissions and blood transfusions due to chronic kidney disease secondary to diabetic nephropathy. She is a housewife with a low socioeconomic status. A family history of mycetoma was noted; her son has bilateral lower limb eumycetoma. Clinically she looked unwell and pale. She was haemodynamically stable, with a pulse rate of 72 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 130/70 mmHg. Her head and neck examinations were unremarkable. A respiratory examination showed no signs of respiratory distress, and the trachea was central, but the movement of the left side of the chest was reduced. A 2 cm in diameter sinus discharging an exudative material with black grains was noted in the midaxillary line of the left chest. The discharge was noted to increase with cough (Fig 1). There was a decrease in air entry and stony dullness on the left side but no added sounds. Other systems were unremarkable. Investigations showed a haemoglobin level of 5.0 g/dl with normal leucocyte count and platelets. Her random blood glucose level was elevated at 324 mg/dl. There was evidence of chronic kidney disease, with urea 94 mg/dl and creatinine 3.2 mg/dl. She was hyponatremic with a serum sodium of 129 mmol/l and a normal K + of 4.6 mmol/l. A liver function test showed an elevated alkaline phosphatase (ALP) of 228 IU/l; otherwise, other enzymes were normal, with aspartate aminotransferase (AST) 6 IU/l and alanine aminotransferase (ALT) 4 IU/l. Total protein was normal at 6.9 g/dl, but a low serum albumin (1.8 g/dl) was noted. C-reactive protein was 11 mg/l, and a viral screening was negative. A urinalysis was positive for PLOS Neglected Tropical Diseases | https://doi.

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