Form 0920-1385 Mycetoma case report form

Form Approved

OMB No. 0920-1385

Exp. Date: 3/31/26

Case report form: Eumycetoma

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Patient demographic characteristics

Unique patient ID: ___________ (site_####)

Site submitting case: ___________

Location of residence for patient (ZIP Code): _____________ OR [] Unknown

Age at diagnosis (years): ____________

Assigned sex at birth: [] Male [] Female OR [] Unknown

Gender identity: [] Male [] Female [] Transgender, non-binary, or another gender

[] Prefer not to answer/Decline OR [] Unknown

Race and/or ethnicity (select all that apply and enter additional details in the spaces provided):

[] American Indian or Alaska Native

Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

[] Asian – provide details below

[] Chinese [] Asian Indian [] Filipino [] Vietnamese [] Korean [] Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

[] Black or African American – provide details below

[] African American [] Jamaican [] Haitian [] Nigerian [] Ethiopian [] Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. ____________________________________________

[] Hispanic or Latino – provide details below

[] Mexican [] Puerto Rican [] Salvadoran [] Cuban [] Dominican [] Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc. ____________________________________________

[] Middle Eastern or North African – provide details below

[] Lebanese [] Iranian [] Egyptian [] Syrian [] Iraqi [] Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc. ____________________________________________

[] Native Hawaiian or Pacific Islander – provide details below

[] Native Hawaiian [] Samoan [] Chamorro [] Tongan [] Fijian [] Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc. ____________________________________________

[] White – provide details below

[] English [] German [] Irish [] Italian [] Polish [] Scottish

Enter, for example, French, Swedish, Norwegian, etc. ____________________________________________

Monthly household income (USD) _____________________________

Occupation at time of presumed infection: ____________________________

Industry at time of presumed infection: ______________________________

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Underlying medical conditions (active or present in the 2 years before symptom onset)

Diabetes mellitus [] Yes [] No [] Unknown

Chronic kidney disease [] Yes [] No [] Unknown

If yes, on dialysis? [] Yes [] No [] Unknown

If yes, GFR < 60? [] Yes [] No

Liver cirrhosis? [] Yes [] No [] Unknown

Chronic hepatitis without cirrhosis? [] Yes [] No [] Unknown

If yes, [] Hep B [] Hep C

Immunocompromising condition [] Yes [] No [] Unknown

[] HIV infection

[] HIV infection without AIDS (CD4 ≥ 200)

[] HIV infection with AIDS (CD4 < 200) or chart diagnosis of advanced HIV disease

[] Cancer diagnosis, specify ________________

[] On chemotherapy, specify ___________________

Date of cancer diagnosis (mm/dd/yyyy): ________________ 

[] Transplant

[] Solid organ, specify organ ________________

[] Hematologic (stem cell)

Date of transplantation (mm/dd/yyyy): ________________ 

[] Immunosuppressive therapy, specify ________________

[] Other immunocompromised condition, specify _______________

Other major underlying condition not listed (specify): ________________________ 

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Exposure history

Has patient traveled or lived internationally in their life? [] Yes [] No [] Unknown

• Country 1 ____________; Approximate duration of stay (years): 

• Country 2 ____________; Approximate duration of stay (years): 

• Country 3 ____________; Approximate duration of stay (years): 

• Country 4 ____________; Approximate duration of stay (years): 

• Country 5 ____________; Approximate duration of stay (years): 

Did the patient immigrate to the United States? [] Yes [] No [] Unknown

If yes, date of immigration (mm/dd/yyyy): ___________________

If yes, country immigrated from: _________________

Any traumatic inoculation ever recalled? [] Yes [] No [] Unknown

If yes, please describe geographic location (e.g., city, state): ______________

If yes, please describe the material involved (e.g., thorns, branches): _________

If yes, please describe any weather events (e.g., hurricane, flood): ____________

If yes, please indicate approximate date of traumatic inoculation (mm/dd/yyyy): _____________

Most likely source of infection, according to clinician ________________________________

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Diagnosis

Did patient have health care facility visits (health center, hospital, etc.) for mycetoma symptoms before visit with mycetoma diagnosis? [] Yes [] No [] Unknown 

If yes, how many visits? ____________ 

Were there misdiagnoses before being diagnosed with mycetoma [] Yes [] No [] Unknown 

What misdiagnoses, if any, did this patient have before being diagnosed with mycetoma (in the last 12 months):  

• Please list all misdiagnoses: ____________________________________________ 

Laboratory testing (associated with diagnosis):

[] X-ray [] Not performed [] Unknown if performed

date of imaging: ____________; result: ______________________

[] MRI [] Not performed [] Unknown if performed

date of imaging: ____________; result: ______________________

[] Ultrasound imaging [] Not performed [] Unknown if performed

date of imaging (mm/dd/yyyy): ____________; result: ______________________

[] CT Scan [] Not performed [] Unknown if performed

date of imaging (mm/dd/yyyy): ____________; result: ______________________

[] Histopathology [] Not performed [] Unknown if performed

date (mm/dd/yyyy): ____________; type of stain: __________

result: ______________________

[] Cytology [] Not performed [] Unknown if performed

date (mm/dd/yyyy): ____________; result: ______________________

[] Fungal grain culture [] Not performed [] Unknown if performed

date of collection (mm/dd/yyyy): ____________; Positive/Negative: _____________ Organism(s): _____________________;

[] Broad range sequencing [] Not performed [] Unknown if performed

date of collection (mm/dd/yyyy): ____________; Type (e.g., 18s, ITS): ____________

Positive/Negative: _____________ Organism(s): _____________________;

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Signs and symptoms noted during patient interview:

Signs & Symptoms	Yes/No	Onset Date if Known
Localized swelling
Openings on the skin (sinuses)
Discharge containing grains
Macroscopic grain size
Microscopic grain size
Lymph node involvement
Bone involvement
Pain
Itching
Other symptoms, please describe:_______

Please describe the specific location on the body of the mycetoma lesion(s) (please mark all that apply for multiple areas affected):

[] Head and neck

[] Trunk

[] Upper limbs

[] Buttocks, perineum, genitals

[] Lower limbs

Additional comments on anatomical location: ___________________________________

Clinical size of mycetoma lesion: Length (cm): ______________; Width (cm):_______________ 

Color of grains:

[] Black

[] White/yellow

[] Red

[] No visible grains

Did mycetoma cause any form of disability: [] Yes [] No [] Unknown 

If yes, please fill out the table below:

Disability	Yes/No	Onset Date	Number of days with disability	Inability to work (Y/N)
Mild motor impairment (has some difficulty in moving around but is able to walk without help)
Moderate motor impairment (has some difficulty in moving around, and difficulty in lifting and holding objects, dressing and sitting upright, but is able to walk without help)
Severe motor impairment (is unable to move around without help, and is not able to lift or hold objects, get dressed or sit upright)

Treatment

Was the patient treated for eumycetoma? 

[] Yes [] No [] Unknown

If yes, list all therapeutic agents (e.g., antifungals, immune response modulators, antibiotics, steroids) in the table below:

Therapeutic Agent Name	Max Daily dose (mg/day)	Route (e.g., IV, PO, IT)	Start Date	Duration   of Therapy	Therapy ongoing   at time of   abstraction	Discontinued due to toxicity. If yes, describe toxicity	Therapeutic Drug Monitoring (e.g., serum level of antifungal)
			___ / ___ / ______	_____days	[] Yes [] No	[] Yes [] No  ---------------------  ---------------------	[] Yes [] No  Level 1: Date: Value: Level 2: Date: Value
			___ / ___ / ______	_____days	[] Yes [] No	[] Yes [] No  ---------------------  ---------------------	[] Yes [] No  Level 1: Date: Value: Level 2: Date: Value
			___ / ___ / ______	_____days	[] Yes [] No	[] Yes [] No  ---------------------  ---------------------	[] Yes [] No  Level 1: Date: Value: Level 2: Date: Value
			___ / ___ / ______	_____days	[] Yes [] No	[] Yes [] No  ---------------------  ---------------------	[] Yes [] No  Level 1: Date: Value: Level 2: Date: Value
			___ / ___ / ______	_____days	[] Yes [] No	[] Yes [] No  ---------------------  ---------------------	[] Yes [] No  Level 1: Date: Value: Level 2: Date: Value
			___ / ___ / ______	_____days	[] Yes [] No	[] Yes [] No  ---------------------  ---------------------	[] Yes [] No  Level 1: Date: Value: Level 2: Date: Value

Notes about treatment: __________________________________________________________________________________________________________________________________________________________________________

Did the patient undergo local surgical excision of the eumycetoma lesions: [] Yes [] No [] Unknown

If yes, date of surgical excision (mm/dd/yyyy): _____________

Did the patient receive antimicrobials before local surgical excision? [] Yes [] No [] Unknown

Did the patient undergo regular debridement: [] Yes [] No [] Unknown

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Complications:

Outcome	Yes/No	Onset Date	Notes (e.g., location)
Tissue fibrosis
Ankylosis (abnormal stiffening and immobility of a joint due to fusion of the bones)
Massive destruction of a joint
Pulmonary eumycetoma due to secondary spread from a subcutaneous lesion
Bronchopleural cutaneous fistula
Secondary bacterial infection
Amputation
Lymphedema
Other; specify _______________

Did the mycetoma infection resolve (clinical and radiographic cure)? [] Yes [] No [] Unknown

If yes, what was the date of clinical resolution:

If no, what was date of last follow-up (mm/dd/yyyy):

Did this patient die within 2 years after the mycetoma diagnosis? [] Yes [] No [] Unknown 

If yes, was mycetoma a contributing factor in patient’s death? [] Yes [] No [] Unknown 

Additional comments: __________________________________________________________________________________________________________________________________________________________________________

Appendix 2: Dermatology Life Quality Index Tool

Dermatology Life Quality Index Questionnaire:

1. Over the last week, how itchy, sore, painful, or stinging has your skin problem been?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

2. Over the last week, how embarrassed or self-conscious have you been because of your skin problem?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

3. Over the last week, how much has your skin problem interfered with you going shopping or looking after your home or garden?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

   5. Not relevant

4. Over the last week, how much has your skin problem influenced the clothes you wear?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

   5. Not relevant

5. Over the last week, how much has your skin problem affected any social or leisure activities?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

   5. Not relevant

6. Over the last week, how much has your skin problem made it difficult for your to do any sport?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

   5. Not relevant

7. Over the last week, has your skin problem prevented you from working or studying

   1. Yes

   2. No

   3. Not relevant

      1. If no, over the last week how much has your skin problem been a problem at work or studying?

         1. A lot

         2. A little

         3. Not at all

8. Over the last week, how much has your skin problem created problems with your partner or any of your close friends or relatives?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

   5. Not relevant

9. Over the last week, how much has your skin problem caused any sexual difficulties?

   1. Very much

   2. A lot

   3. A little

   4. Not at all

   5. Not relevant

10. Over the last week, how much of a problem has the treatment for your skin problem been, for example by making your home messy, or by taking up time?

    1. Very much

    2. A lot

    3. A little

    4. Not at all

    5. Not relevant

CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1385).