Interest of Moringa oleifera in the Treatment
of Fungal Mycetoma
Nomtondo Amina Ouédraogo1,2*, Bénilde Marie Ange Tiemtore-Kambou3,2, Nina Astrid Nde/Ouédraogo3,2, Fagnima Traoré4, Muriel Sidnoma Ouédraogo2,5, Gilbert Patrice Tapsoba2,5, Nessine Nina Korsaga/Somé2,5, Fatou Barro-Traoré2, Pascal Niamba2,5 and AdamaTraoré2,5
1Service of Dermatology, Center Raoul Follereau, Burkina Faso
2Unit of Research in Health Sciences, University of Ouagadougou, Burkina Faso
3Department of Radiology and Medical Imaging, Bogodogo District Hospital, Burkina Faso
4Department of Dermatology, Hospital Center Régional, Burkina Faso
5Department of Dermatology, Hospital Center University Yalgado Ouédraogo, Burkina Faso
Submission: January 31, 2017; Published: May 30, 2017
*Corresponding author: Nomtondo Amina Ouédraogo, Service of Dermatology, Center Raoul Follereau, Burkina Faso,
How to cite this article: Ouedraogo NA, Tiemtore-Kambou BMA, NDE/Ouedraogo NA, Traore F, Ouedraogo MS, et al. Interest of Moringa oleifera in the
treatment of Fungal Mycetoma. An Unusual Case. JOJ Case Stud. 2017; 2(5) : 555600. DOI:10.19080/JOJCS.2017.02.555600.
Fungal mycetoma is inflammatory pseudotumor of subcutaneous soft tissue and bone due to exogenous fungi. it evolution is chronic, often polyfistulated with emission of fungal grains. We report a case of a 44-year-old grower with a fungal mycetoma of the foot with bone damage due to Aspergillus fumigatus. The tumefaction partially regressed after 6 months daily consumption of Moringa oleifera seeds. Also called “miracle tree”, M. oleifera is a shrub, growing in a tropical region, having several properties recognized in traditional medicine, its grains would have an antifungal activity. Doppler, by demonstrating hyper vascularization reflecting the presence of inflammatory remodeling controls the activity of the disease, is an interesting, non-invasive factor for the follow-up of the disease.
Mycetomas are pathological processes in which agents of fungal or actinomycotic origin emit grains. They are common in tropical and sub-tropical countries. Fungal mycetomas due to fungi and actinomycotic mycetomas due to actinomycetes . Mycetomas are still endemic in the mycetomic belt (on both sides of the fifteenth northern parallel) where Burkina Faso is located and in which the climate makes possible the survival of the agents (long dry season of at least Seven months followed by a short rainy season) .
Eumycetomas or fungal mycetomas are inflammatory pseudotumors of subcutaneous soft tissues due to exogenous fungi. They are often polyfistulated with an emission of fungal grains and a chronic evolution. They evolve slowly, determining after certain duration of evolution, osseous attacks that involve the functional prognosis, then visceral attacks sometimes fatal . Treatment poorly codified, recourse to long-term antifungals and surgery in the event of associated bone involvement. We report a case of fungal mycetoma of the foot with bone involvement that partially regressed after 6 month regular consumption of seeds of Moringa oleifera.
A 44-year-old man Burkinabe, a farmer, consulted the dermatology department of the Raoul Follereau Center for a polyfistulized tumor of the right foot. The anamnesis did not find any notion of local trauma. The disease had begun 5 years ago by a subcutaneous nodule of the sole of the foot, which gradually increased in volume impeding walking. Clinical examination at admission indicated a firm tumefaction of the anterior 2/3 of the foot, going from the back to the sole of the foot about 15cm in diameter, giving rise to black grains of 1 to 2mm in diameter as well as hematic and nauseous (Figure 1). The examination had not found loco-regional and distant nodes. The neurological examination was normal. The rest of the somatic examination was without anomaly. The biological exploration noted only a moderate increase in sedimentation rate to
36mm at the first hour. The hemogram, liver function, renal
function, muscle enzymes were normal. Histology compatible
with mycetomanoted a polymorphic granulomatous infiltrate
(histiocytes, polynuclear neutrophils and lymphocytes) with
suppuration foci circumscribing small-sized pigmented grains
with irregular contours.
The mycological study concluded a fungal mycetoma by
highlighting Aspergillus fumigatus in the tumor collection.
The X-ray of the right foot performed in frontal incidence and
3/4 revealed bone luminosity with sharp, regular and opaque
contours in the first phalanx of the first radius of the right foot.
A thickening of the cortical bone of the 1st phalanx and the
head of the right 1st margin was noted. There were no other
abnormalities in the bones (Figure 2). CT scan of the feet without
and with injection of contrast agent with reconstruction in soft
parts and in bone window revealed bone deficits hypodense
of cortico-medullary seat, interesting the diaphyso-epiphyseal
regions of the first phalange of the right foot and the head of
the 1st metatarsal. Their contours were sharp, regular and dense.
The sesamoids were dense and atrophic. There was hypertrophy
of the soft parts of the forefoot, enhanced after injection of
contrast medium (Figure 3). No subcutaneous fluid collection
was detected. These imaging aspects led to the conclusion that
the 1st metatarsal head of the 1st metatarsal head and the 1st
right foot phalanx with the thickening of the bone cortex and
thickening of Soft parts of the tarsus facing.
These imaging aspects led to the conclusion that the 1st
metatarsal head and the 1st phalanx of the right radius of the
right foot were found to have type Ia (Madwell Classification)
osteolysis plaques, with thickening of the cortical bone and
thickening of Soft parts of the tarsus facing. Subcutaneous
hypoechoic formations containing hyperechogenic grains,
compatible with a fungic ultrasound. Hyper vascularization at
the Doppler may reflect the presence of active inflammatory
A surgical management associated with a terbinafine
treatment of 1g per day and antiseptic was proposed but did not
meet the consent of the patient, who did not wish to undergo
surgery and did not have financial resources for it and no medical
insurance to cover him. He interrupted the medical follow-up.
Contacted several times by the healthcare team without
success, the patient is finally reviewed after 6 months. The clinical
examination noted a significant clinical improvement of the
mycetoma lesions with a swelling of the tumefaction compared
to the 1/3 middle of the right foot, complete cicatrization of the
polyfistulae lesions of the back of the foot. A regression with
partial healing of the lesions of the foot is observed (Figure 1
& 4). One notes a persistence of blackish lesions in the middle
1/3 and opposite the plantar face of the toes of the foot. The
discomfort with walking has been considerably improved. When
questioned, the patient reported initiating a traditional medicine
treatment consisting of daily oral intake of 4 seeds of Moringa
oleifera (M.oleifera) and applying of the leaves on the lesion for
A mycological control (realized for free) of tumefaction was
negative as well as the aspergillary serology (realized for free)
performed (Ac antiA fumigatus EIA bio rad=0 AU/ml, and Ac anti
A fumigates HAI <80).
Doppler ultrasound (realized for free) performed in
projection of the plantar face of the right foot, visualized
opposite the cutaneous papules, hypoechoic oval beaches.
They had different depth levels in the subcutaneous tissue. The
deepest ones communicated by pertuis with the more superficial
beaches. Within certain deep collections, spontaneously
hyperechoic elements with angular contours, measured between
1 and 2mm corresponding to the grains, were visualized. At the
Doppler, there is an arterial hyper-vascularization within hypoechogenic
rearrangements (Figure 5). An overall thickening of
the soft parts of the right forefoot was noted. These subcutaneous
hypoechoic formations on the plantar surface of the right foot
containing hyperechogenic grains in them, are compatible with a
fungic ultrasound. Doppler hypervascularization may reflect the
presence of active inflammatory remodeling.
The diagnosis of fungal mycetoma of our patient was raised
and retained by the anamnestic aspects: long duration of
evolution, the notion of trauma not recovered. Indeed, the delay
between the occurrence of the disease and the inoculant bite of
the germ being very long, the latter is often forgotten .
The clinical aspect: the polyfistulized swelling of the foot
emitting black grains, the black grains always being of fungal
origin . The attack of the foot is usual and defines the classic
foot of Madurae.
The histological aspect: a polymorphous granulomatous
infiltrate (histiocytes, neutrophilicpolynuclear cells and
lymphocytes) with suppuration foci circumscribing small
pigmented grains with irregular contours suggestive of
mycetoma. This is confirmed by the mycological study which
isolated Aspergillus fumigatus confirming the fungal origin.
The first particularity of this case is the isolation of
Aspergillus fumigatus from mycology. Indeed, the germs usually
incriminated in fungal mycetomas are Madurella Mycetomatis in
our context [2,3]. Verma & Kotwal [4,5] studies have reported
Aspergillus as the germ involved in eumycetoma [4-7].
The second feature is its clinical regression with M. oleifera
seeds consumption, which resulted in complete healing of the
lesions of the back of the foot and partial healing of the plantar
surface in 6 months.
M. oleifera is a small shrub of the family of Moringaceae,
native to India, growing in tropical and subtropical zone,
including 13 species, known in traditional oriental medicine for
its medicinal properties [8,9]. The species M. oleifera Lam or M.
pterogo sperma Gaertn is the most popular in Africa notably in
Burkina Faso Called “miracle tree”, all parts of the plant (leaves,
bark, seeds, flowers, roots) have significant pharmacological
activities: antifungal, hypocholesterolemic, hypoglycemic, antitumor,
anti-infectious, antioxidant, antibacterial. Antifungal
activity on certain skin fungi such as Trichophyton rubrum,
Trichophyton mentagrophytes, Epidermophyton floccosum and
Microsporumcanis [10-13]. Thus, in our patient, M. oleifera , by
his antifungal properties, would have permitted the complete
melting of the tumefaction of the foot, the partial cicatrization of
mycetoma of the foot? These questions could serve as a hypothesis
for further studies to confirm the antifungal activity of M. oleifera
active in the eumycetoma. This anti-fungal activity may prove to
be a major step forward in the therapeutic management of fungal
mycetomas, especially in developing countries where long-term
treatment and the financial inaccessibility of antifungal drugs
are a barrier to taking in efficient charge.
The last feature is that the Doppler showed active internal
inflammation despite clinical improvement. According to
Dikhaye, the use of imaging is essential to the assessment of pretherapeutic
extension, but also to the evolutionary follow-up of
the bone involvement, essentially and the soft parts of fungal
mycetoma, conditioning the indication of medical and surgical
treatment as well as the surgical gesture to be realized .
The involvement outside the soft parts can be manifested at the
articular and extra synovial level as in the case of Thiouri where
there was a fusing carpet. Iniesta  found the same lesions in
the type of destructions and fusion of the leg and foot bones after
20 years of evolution [14,15].
Osteolysis has been described radiologically with varying
degrees of developmental outcome. Chronic osteitis (X-ray
builder and destructive aspect) and endemic Kaposi disease
may be discussed but clinic and mycology were directed towards
fungal mycetoma [1,16,17].
At the Doppler, the presence of inflammatory rearrangement
always active on the plantar face, indicates the persistence
of the activity of the germ in this part of the foot reached. The
ultrasound, non-invasive, reproducible, inexpensive appears best
adapted in our working context. Mycetomas give characteristic
ultrasound images described by Sudanese authors: multiple
cavities with thick walls without acoustic reinforcement .
It is possible to distinguish, according to these same authors,
the action mycetomas of the fungal mycetomas according to the
echo graphic aspects. The former have poorly individualized
echoes corresponding to small and cement less grain in most
species. They are usually grouped together at the bottom of the
cavities. Echoes are sharp, shiny, hyper reflective in black fungal
fungal mycetomas. Ultrasound makes it possible to delineate
the extension of the mycetoma more precisely than the clinical
This finding reveals a rare fungal mycetoma cause:
Aspergillus fumigatus. It also arouses interest in M. oleifera in
the management of eumycetoma, which would be appreciable in
our working context. Further studies could validate or invalidate
this hypothesis. Doppler ultrasound could be an interesting
examination for the monitoring and surveillance of fungal
mycetoma, which can take several years to manage and help
with therapeutic decisions.