Antimicrobial Chemotherapy
1 May 2024

An updated list of eumycetoma causative agents and their differences in grain formation and treatment response

Special Series: Fungi’s Most Wanted 


In 2023, the World Health Organization designated eumycetoma causative agents as high-priority pathogens on its list of fungal priority pathogens. Despite this recognition, a comprehensive understanding of these causative agents is lacking, and potential variations in clinical manifestations or therapeutic responses remain unclear. In this review, 12,379 eumycetoma cases were reviewed. In total, 69 different fungal species were identified as causative agents. However, some were only identified once, and there was no supporting evidence that they were indeed present in the grain. Madurella mycetomatis was by far the most commonly reported fungal causative agent. In most studies, identification of the fungus at the species level was based on culture or histology, which was prone to misidentifications. The newly used molecular identification tools identified new causative agents. Clinically, no differences were reported in the appearance of the lesion, but variations in mycetoma grain formation and antifungal susceptibility were observed. Although attempts were made to explore the differences in clinical outcomes based on antifungal susceptibility, the lack of large clinical trials and the inclusion of surgery as standard treatment posed challenges in drawing definitive conclusions. Limited case series suggested that eumycetoma cases caused by Fusarium species were less responsive to treatment than those caused by Madurella mycetomatis. However, further research is imperative for a comprehensive understanding.

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Author Bios

Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
Wendy van de Sande is an associate professor in medical mycology at ErasmusMC, the Netherlands. She has been studying mycetoma since 2001 and obtained her PhD from Erasmus University in Rotterdam in 2007 cumlaude. She published 128 peer-reviewed papers on mycetoma. She and her team developed several diagnostic tools to identify the causative agents at the species level. These tools are currently used worldwide. She also leads the biological screening in the Mycetoma Open Source drug discovery program MycetOS. She is a founding member of the global mycetoma working group, convener of the eumycetoma working group at the International Society of Human and Animal Mycoses and vice chair of the skinNTD subgroup of the Diagnostic Technical Advisory Group of the World Health Organization.
The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
Prof. Ahmed Fahal, a distinguished surgeon and professor, has significantly contributed to medical research, education, and the management of mycetoma. Trained at the University of Khartoum and in the UK, he attained the position of consultant surgeon at Soba University Hospital and a professorship at the University of Khartoum. He excels in mycetoma and tropical surgery, founding the globally recognized Mycetoma Research Centre at the University of Khartoum, WHO Collaborating Center on Mycetoma and Skin NTDs. His extensive research, with over 300 peer-reviewed articles, positions him among the top 2% of global scientists. Playing fundamental roles in educational development and scientific research agencies, he currently serves as the Vice President of the Arab Scientific Research Councils Federation. Prof. Fahal's enduring legacy encompasses groundbreaking clinical trials, the establishment of mycetoma satellite centers, and vocational training for mycetoma patients, reflecting his dedication to comprehensive healthcare. His numerous awards underscore his outstanding achievements in scientific innovation and research.

Information & Contributors


Published In

cover image Clinical Microbiology Reviews
Clinical Microbiology Reviews
Volume 37Number 213 June 2024
eLocator: e00034-23
Editor: Graeme N. Forrest, Rush University, Chicago, Illinois, USA
PubMed: 38690871


Published online: 1 May 2024


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  1. mycetoma
  2. diagnosis
  3. susceptibility
  4. itraconazole
  5. biofilm
  6. grain
  7. neglected tropical disease
  8. molecular diagnostics



Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan


Graeme N. Forrest
Rush University, Chicago, Illinois, USA


Rod Hay
Ad Hoc Peer Reviewer
The International Foundation for Dermatology, London, United Kingdom
Ferry Hagen
Ad Hoc Peer Reviewer
Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands


The authors declare no conflict of interest.

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