 Hello everyone. I'm here to present a topic on ultrasound imaging in the myzotoma and correlation with the MR and CT. So myself Dr. Sumit here from GMC Aurangabad. And here we start now. Myzotoma is a chronic nanometer infection of the skin, subcutaneous tissue and which can extend to the bone with the high morbidity. Males are more affected than the females, possibly due to the outdoor and occupational exposures. It predominantly affects the foot, hands and legs, but may involve any part of the body. This is also commonly referred as Modura Podasi, it was first described in the Madurai in India by Dr. John Gill in 1842. Vandekhi Carter in an 1860 coin term mastoma. The region is clinically characteristic by the triad of tumor infection, discharging sinus and the grains that are formed by the colonies of the causing organisms. It is very important to differentiate mastotoma from other infections in your persons. Depending on the organism, it can be either ectromycotic or eumicotic. The disease is common in people, low social administrators, farmers and field workers, mostly who work barefoot, putting them at a great risk of acquiring trauma and infection by these pathogens. This is listed by the World Health Organization WHO as a neglected tropical disease. Although it is a prevailing worldwide, it tends to be a major health problem in the tropical and subtropical countries such as India. The aims and objectives of this topic is that the aim of the study is to find out ultrasonic graphic imaging findings of the mastotoma and emphasis on the role of UHE in the diagnosis and to correlate the UHE findings of the mastotoma with MRI and CT scan imaging findings. The methods and materials we use here. This is an observation study. I entered the department of radio diagnosis in the College of Aurangabad during the period of 2022 to 2023. Approval from the institutional ethics committee was taken before the beginning of the study. The examination carried out after signing the informed consent by the patients. Total 10 patients with the foot mastotoma referred from the surgery and rheumatology from an underwent examination with the sansom HS50 UHE machine. That is an GE3 Tesla MRI machine and Siemens definition as 128 slice CT scan machine, including this study. Contrast was used whenever necessary and with proper consent. The UHE images obtained in different planes on grayscale and ocular Doppler imaging. So MRI sequences were often used in a phase array surface coil and instead of T1 and T2 weighted proton density and fat suppression stir and DWI images in different planes. CT images were obtained with present protocol. Diagnosis was also conformed with the biopsy and bacterial screening. Out of 10 patients, 7 were active with mastotoma and 3 were reused with mastotoma. The dotted circle sign was observed on the ultrasound imaging in 10 cases. In all of them, which is revealed at the centre of the hyperbolic area surrounded by the hyperbolic tissue and an increased vascularity on the Doppler study. The dotted circle sign was also observed on MRI and 10 patients. The MRI findings were most clearly seen in the T2 weighted imaging stir sequences as well as fat suppress T1 weighted sequences after injection of the intravenous gadolinium. MRI images shows multiple discrete millimetre at the crown to oval. T1 isointestine T2 stir hyperintestine leaches with hypointestine central nodules involving the subcutaneous tissue of the foot with peripheral low signal interactive hypocytes in between corresponding to mastotoma's grains. So the central hypointestine dots were observed within them making the characteristic dotted circle sign. Using MRI also revealed bone environment in these patients. CT depicted the extent of the bone environment in the 9% more precisely. So now we want distribution according to age. So we are distributed according to the age like the number of cases and the percentage of them from the range of 0 to 20, 20 to 40, 40 to 60, more than 60. So likewise, you can see this chart and distribution according to sex. According to the male and female, there are male 8 cases were there and females 22 cases were there. So this way we have pie chart for that. Imaging cat is from USG, MRI and CT. So soft tissue swelling is noted 10 plus in USG all the 10 patients has just finding soft tissue swelling was there in the USG also in MRI also CT scan also. The dotted circle sign was found in USG and MRI only from the CT. More involvement in 4 patients in USG, 5 patients in MRI and 9 patients in CT scan and color topography findings are in the USG. So table shows us swelling on a million, abbreviated plus or not minus and not abbreviated means not minus. So there is a case now here, a 70 year old male patient, farmer by operation patient with the left foot swelling and discharging sinus and I think 7 years. It started as a small painless swelling at the sole, swelling for the increasing in size despite continued medical treatment at the local level. The patient was not the victim in immunocompetent. So you can see the images of the patients in the X-ray finding here, X-ray image. Now we will move for the USG. At some examination showed soft tissue swelling and multiple conglomerated hyperquick lesions with a hyperquick center doing dotted circle sign. See this is a hyperquick center and around that is a hyperquick area. So we can see that it's the hyperquick area is a inflammatory granuloma, midline is the fungal ball or grain at hyperquick. And the outermost hyperquick is the fibrous matrix. You can see that. Usually showing soft tissue swelling and multiple conglomerated hyperquick lesions with a hyperquick center doing dotted circle sign and there is vasculature on the top of the study. We can see the top of the study. It's a raised vasculature here and these lesions are here and see that. So there is a diffuse. Extensive soft tissue swelling and involving those liquidation, subcutaneous planes and underlying muscles of the left foot and ankle lesion. Multiple rounded uterus signal intensity lesions happening isotope hyperintense on the T1 weighted imaging. So MRI imaging. Now we can see this lesions is also giving the dotted circle sign as shown and it shows this tissue on the DWI. And showing peripheral enhancement on the post-quantus study with central hyperintensity giving dotted circle sign. So here we can see the fungal ball grains. Here is the inflammatory granuloma and this is the outermost with the fibrous matrix. Here is the picture. Soft tissue swelling with bone environment. And here is the micropology. This report is from the sample. First was expected here. And on the gram standing here are plenty pustules. Gram peru to filamentous bacillus. On 3% kiosk mounting. No fungal elements seen. Z-staining. No acid bacillus seen. From the finding of the gram standing it is used to actinomycetoma compression. So see here is the next case. The second case. If a year old male farmer planted with the left foot swelling and the desaline sign is seen. Five years. The patient was non-labbitic and immunocompetent. So USG foot imaging is shown here. See the foot showing soft tissue swelling here. Protein circle sign is there. And there is vascular tonic opacity in the mastodoma. See. Here you can see the race vascularity and the regions. Protein circle. So MR imaging of the foot of this patient. You can see the innumerable round of rounded ulterior signals and instant intensity lesions. Happening eyes to hyperintense on T1-invited imaging. Intermediate in signal intensity on the T2-vited and Pd imaging. And showing the restriction on the PWA. So you can see this ulter sensory regions. Core feet. And core ulter sensory regions. You can see the MR showing peripheral enhancement on the post-contest study with the central hyperintensity giving dot-in-circle sign. Neural and skin supprenent tissue. Intermuscle distal tibia. All tarsals and all metastasis and pharyngeas. Upper phytosis of mastodoma. See. Here are the lesions. Giving dot-in-circle sign. Here are the post-contest images. All of them. So left foot axial PDFSE. And sag T1FSE post-contest showing dot-in-circle sign. Magnified image here. Dot-in-circle sign. City foot. Showing diffuse pony Australitic areas with joint involvement. You can appreciate that. Involving the joint. Australitic areas. Discussion. Mycetoma. This is devastating. Extensive tissue destruction. Inner study out of 10 patients. Maximum patients were found in each of the 20 to 40 years of age. 60% patients. Which corresponded to the most active age group. Distribution according to the sex shows male freedom. Male to female ratio was 8 to 2. Mycoti patients were more than the mycoti patients. 7 is to 3 ratio. Ultrasonic imaging reveals the central hyperuquic area delimiting by delimited by hyperuquic tissue. Giving the characteristic dot-in-circle sign. Doppler image shows the increased vascularity also there. MRF endings were most clearly seen in the T2 star sequences. And fat suppressed T1 weighted sequences. After the ingestion of intravenous contrast. Cytostic dot-in-circle sign was fairly evaluated in the MRF new age. But not in CT. So the dot-in-circle sign is clearly visible. Cytostic and highly specific to diagnosis of mycetoma on both MRF new age. Obviating the need for the multiple new age biopsies. A study by the Anita Sen and Rajesh Pillay. And Ashwini Kumari and others. To show the similar findings. CT findings in the mycetoma are not specific. But are important in indicating the bone involvement. As it can detect bone destruction. Erosions, periostal reactions. Substitute involvement. So helical CT is superior to the plein CT. As it allows three dimensional reconstruction. And more patient information on the degree of organ involvement. And can help in surgical management. So early diagnosis and treatment. Can prevent morbidity and improve the prognosis of this. So what is the conclusion? Conclusion in the conclusion. The study suggests that mycetoma has characteristic USG imaging features. So both MRF and USG can aid in the early diagnosis. And treatment of mycetoma. When they demonstrate the imaging features of the dot-in-circle sign. Responding to the inflammatory cannuloma with the central fungal. Again avoiding invasive biopsies. So we can prevent biopsies from bi- because of that. It's a definite sign. In the MRF and USG. So ultrasonic therapy being easily accessible. Fisible, rapid, repeatable and radiation free. Is very useful for diagnosis. Treatment and the follow-up of the mycetoma patients. Which will limit the morbidity and improve the prognosis. Mycetoma diagnosis with the USG is very helpful. For these patients who are generally from ruler. Low socio-economic backgrounds. Where the MRF, CT, biopsy and bacterial screening facilities are out of their reach. So USG really puts a key role in these patients. Who are in the ruler. Low socio-economic backgrounds. Here we end our presentation. Thank you so much for listening. These are some references to this. Thank you.