Spinal eumycetoma mimicking compressive myelopathy: Madurella grisea as a rare cause

Eumycetoma rarely involves the spine, with most cases affecting the extremities in tropical regions. Spinal involvement causing compressive myelopathy is exceptionally rare and poses significant diagnostic challenges, often mimicking tuberculosis or neoplastic lesions.

A 34-year-old woman presented with progressive lower back pain radiating to the left lower limb, neurogenic claudication, and a palpable lumbar swelling. She had sustained minor trauma five months prior. Magnetic resonance imaging revealed erosive changes at L1 with posterior epidural collection (D12-L2) causing thecal sac compression, bilateral psoas extension, and an impending sinus tract. Initial clinical suspicion favored spinal tuberculosis.

Surgical decompression was performed, revealing adherent granulomatous tissue. Histopathological examination demonstrated fungal grains with characteristic pigmented hyphae, confirming the diagnosis of eumycetoma. Microbiological culture identified Madurella grisea, an uncommon etiological agent in northern India.

The patient experienced significant neurological improvement postoperatively and was commenced on prolonged antifungal therapy with itraconazole. She remained clinically stable at the 6-month follow-up, with no evidence of recurrence.

Spinal eumycetoma should be considered in the differential diagnosis of atypical compressive myelopathy in endemic regions, particularly when paraspinal swelling or a history of trauma is present. Tissue diagnosis is essential to avoid misdiagnosis as tuberculosis. Combined surgical decompression and prolonged antifungal therapy are crucial for favorable outcomes.