<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT04401969</url>
  </required_header>
  <id_info>
    <org_study_id>Mycetoma Study</org_study_id>
    <nct_id>NCT04401969</nct_id>
  </id_info>
  <brief_title>Tissue Microenvironment Signatures of the Mycetoma Granuloma</brief_title>
  <official_title>Studying the Tissue Microenvironment Signatures of the Mycetoma Granuloma</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>University of Khartoum</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
    <collaborator>
      <agency>University of York</agency>
      <agency_class>Other</agency_class>
    </collaborator>
  </sponsors>
  <source>University of Khartoum</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      Mycetoma is the most neglected of the neglected tropical diseases. It is caused by certain&#xD;
      fungi or bacteria. It is endemic in many tropical and subtropical regions and Sudan seems to&#xD;
      be the mycetoma homeland. This chronic subcutaneous destructive and disabling inflammatory&#xD;
      disease has many serious medical and socio-economic impacts on patients, community and health&#xD;
      authorities. This work may suggest new therapeutic options for mycetoma that target the&#xD;
      inflammatory pathogenic pathway and hence help in designing universal treatment options for&#xD;
      mycetoma patients.&#xD;
&#xD;
      Two overlapping aims were investigated in this project to advance our overall goals:&#xD;
&#xD;
        1. Profiling the immune/inflammatory signatures in the tissue microenvironment of&#xD;
           fungus-induced mycetoma lesions&#xD;
&#xD;
        2. Profiling the immune/inflammatory signatures in the tissue microenvironment of&#xD;
           bacteria-induced mycetoma lesions.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Mycetoma is a chronic, specific, subcutaneous granulomatous, progressive and disfiguring&#xD;
      inflammatory disease. It is caused by true fungi or by certain bacteria and hence it is&#xD;
      usually classified into eumycetoma and actinomycetoma respectively. Madurella mycetomatis is&#xD;
      the commonest eumycetoma causative agent, while Streptomyces somaliensis and Nocardia&#xD;
      brasiliensis are the common causative organisms for actinomycetoma. The triad of a painless&#xD;
      subcutaneous mass, sinuses formation and purulent or sero-purulent discharge that contains&#xD;
      grains is pathognomonic of mycetoma. The inflammatory subcutaneous granuloma usually spreads&#xD;
      to involve the skin and the deep structures, resulting in destruction, deformity and loss of&#xD;
      function, occasionally it can be fatal. The foot and hand are the most frequently affected&#xD;
      sites seen in 82% of cases. In endemic areas, other parts of the body may be involved such as&#xD;
      the knee, arm, leg, head and neck, thigh and perineum. No age is exempted in mycetoma;&#xD;
      however, it occurs more frequently in young adult men in the age range 20-40 years and almost&#xD;
      30% of reported patients were young students.&#xD;
&#xD;
      The true incidence and prevalence of mycetoma world-wide is not precisely known. It is&#xD;
      interesting to note that most of the reported mycetoma data are related to hospital patients&#xD;
      with advanced disease. This is attributed to the nature of mycetoma which is usually&#xD;
      painless, slowly progressive and the late presentation of the majority of patients due to the&#xD;
      poor health education, lack of health facilities and financial constraints.&#xD;
&#xD;
      The worldwide distribution of mycetoma varies widely. It is endemic in many tropical and&#xD;
      subtropical regions and prevails in the mycetoma belt, which includes the countries of Sudan,&#xD;
      Somalia, Senegal, India, Yemen, Mexico, Venezuela, Columbia, Argentina, and a few others. The&#xD;
      African continent seems to have the highest burden and prevalence of the disease. It has also&#xD;
      been extensively reported from India. However, mycetoma has been reported in many temperate&#xD;
      regions as well. There are a few reports on mycetoma from the USA, Sri Lanka, Germany, Egypt,&#xD;
      Turkey, Philippines, Japan, Lebanon, Thailand, Saudi Arabia, Tunisia and Iran.&#xD;
&#xD;
      The proper treatment of mycetoma depends mainly on accurate diagnosis. It is essential to&#xD;
      identify the causative organism to the species level and the current tests for that are the&#xD;
      classical grains culture, surgical biopsy histopathological examination and various molecular&#xD;
      techniques such as PCR. Various imaging techniques such as conventional radiology,&#xD;
      ultrasonography, CT scan and MRI are in use to determine the disease extend. Most of these&#xD;
      tests and techniques are invasive, expensive and of low sensitivity and specificity.&#xD;
      Furthermore, they are not available in the mycetoma endemic regions and hence there is a&#xD;
      desperate need forth easy to use, field-friendly test to identify the causative agent.&#xD;
&#xD;
      The management of this distressing and devastating disease is disappointing. The treatment&#xD;
      depends mainly on the aetiological agent, the site and extend of the disease. Until recently,&#xD;
      the only available treatment for mycetoma was amputation or multiple mutilating disfiguring&#xD;
      surgical excisions. Combined medical treatment in the form of antifungals for the eumycetoma&#xD;
      and antibiotics and antimicrobial agents for actinomycetoma and various surgical excisions is&#xD;
      the gold standard in mycetoma.&#xD;
&#xD;
      Reports on medical treatment in eumycetoma are scarce and inadequate. Over the years and till&#xD;
      now, the treatment of eumycetoma was based on personal clinical experience and on the results&#xD;
      of sporadic case reports, rather than controlled clinical trials. In general, massive&#xD;
      surgical excisions or amputation of affected part is the treatment of choice for eumycetoma.&#xD;
      Various antifungal agents have been tried with little success. This is perhaps surprising, as&#xD;
      the eumycetoma causative agents are low-grade infective organisms and their eradication&#xD;
      should be readily achieved by the administration of antifungal drugs. Generally,&#xD;
      actinomycetoma is amenable to medical treatment with antibiotics and other chemotherapeutic&#xD;
      agents. Combined drug therapy is always preferred to a single drug to avoid drug resistance&#xD;
      and for disease eradication.&#xD;
&#xD;
      Medical treatment for both types of mycetoma must continue until the patient is clinically,&#xD;
      radiologically, ultrasonically and cytologically cured. Recurrence is more common after an&#xD;
      incomplete or irregular course of medical treatment. With patient non-compliance, there is a&#xD;
      good chance for the organism to develop drug resistance.&#xD;
&#xD;
      The study was conducted at the Mycetoma clinic at the Mycetoma Research Centre (MRC),&#xD;
      Khartoum Sudan. Patients were enrolled into the study after written informed consent was&#xD;
      obtained in line with the Declaration of Helsinki.&#xD;
&#xD;
      Patients were categorized into three groups;&#xD;
&#xD;
        -  Patients with eumycetoma lesions (n=10)&#xD;
&#xD;
        -  Patients with actinomycetoma lesions (n=12)&#xD;
&#xD;
        -  Patients with lesions of unknown causality (n=6)&#xD;
&#xD;
      Formalin fixation and paraffin embedding was performed at the MRC according to standard&#xD;
      procedures.&#xD;
&#xD;
      Fine needle aspirates (FNA) was collected for flow cytometry at the same time and at the same&#xD;
      location of the lesion in the body.&#xD;
&#xD;
      Aspirates were frozen at -80C for future analysis. Concurrently, 15 ml of blood was taken&#xD;
      from each patient for immunological function assays.&#xD;
&#xD;
      Peripheral blood mononuclear cells were prepared using standard protocols and stored in&#xD;
      liquid nitrogen till required.&#xD;
&#xD;
      5 ml of blood was collected in Paxgene tubes for transcriptomics analysis.&#xD;
&#xD;
      Immunohistochemistry Immunohistochemistry was performed at University of York, UK. Formalin&#xD;
      fixed paraffin embedded (FFPE) sections were analysed using the 700 gene Nanostring PanCancer&#xD;
      Immune Cell profiling panel to obtain a high level view of the immune/inflammatory signature.&#xD;
&#xD;
      Serial sections were subjected to highly multiplexed antibody staining using the Nanostring&#xD;
      Digital Spatial Profiling system to obtain a comprehensive and spatially resolved insights&#xD;
      into lesion microenvironment.&#xD;
&#xD;
      Candidate pan-mycetoma targets identified by these approaches were confirmed using&#xD;
      immunofluorescent antibodies and RNA-fluorescent in situ hybridisation.&#xD;
&#xD;
      All data was recorded as digitised whole slide images for publication and archiving.&#xD;
&#xD;
      Antigen specific T cell responses T cells responses analysis were performed at Institute for&#xD;
      Endemic Diseases, University of Khartoum.&#xD;
&#xD;
      Peripheral blood mononuclear cells (PBMCs) from patients and age and sex matched healthy&#xD;
      control from endemic area were stimulated for 7 days with fungus and bacterial lysates. IFN,&#xD;
      IL-17, IL-4 and IL-10 responses were determined by ELISPOT assay.&#xD;
&#xD;
      Flow cytometry on FNBs were performed with panels of antibodies to evaluate T cell and&#xD;
      myeloid cell phenotype.&#xD;
&#xD;
      Whole blood transcriptomics Blood were collected into Paxgene and stored at - 80c. RNA were&#xD;
      extracted from stored samples Full whole blood transcriptomic data was obtained by RNA-Seq.&#xD;
&#xD;
      Cytokine measurements in mycetoma aspirates were undertaken using commercially available&#xD;
      ELISA kits.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Completed</overall_status>
  <start_date type="Actual">March 7, 2019</start_date>
  <completion_date type="Actual">April 16, 2019</completion_date>
  <primary_completion_date type="Actual">April 16, 2019</primary_completion_date>
  <study_type>Observational</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <observational_model>Case-Only</observational_model>
    <time_perspective>Cross-Sectional</time_perspective>
  </study_design_info>
  <primary_outcome>
    <measure>immune cell phenotypes</measure>
    <time_frame>24 months</time_frame>
    <description>detection of immune cell phenotypes in mycetoma lesions</description>
  </primary_outcome>
  <primary_outcome>
    <measure>antigen-specific t-cell responses</measure>
    <time_frame>24 months</time_frame>
    <description>detection of t cell and myeloid cell phenotype in peripheral blood</description>
  </primary_outcome>
  <number_of_groups>3</number_of_groups>
  <enrollment type="Actual">28</enrollment>
  <condition>Mycetoma</condition>
  <arm_group>
    <arm_group_label>Patients with eumycetoma lesions</arm_group_label>
    <description>Patients with eumycetoma lesions</description>
  </arm_group>
  <arm_group>
    <arm_group_label>Patients with actinomycetoma lesions</arm_group_label>
    <description>Patients with actinomycetoma lesions</description>
  </arm_group>
  <arm_group>
    <arm_group_label>Patients with lesions of unknown causality</arm_group_label>
    <description>Patients with lesions of unknown causality</description>
  </arm_group>
  <biospec_retention>Samples With DNA</biospec_retention>
  <biospec_descr>
    <textblock>
      Needle biopsy samples from mycetoma lesions&#xD;
&#xD;
      Fine needle aspirates from the matching mycetoma lesion&#xD;
&#xD;
      Whole blood for RNA analysis&#xD;
    </textblock>
  </biospec_descr>
  <eligibility>
    <study_pop>
      <textblock>
        Patients are recruited from Soba University Hospital Mycetoma clinic&#xD;
&#xD;
        10 patients with eumycetoma lesions 12 patients with actinomycetoma lesions 6 patients with&#xD;
        lesions of unknown causality&#xD;
      </textblock>
    </study_pop>
    <sampling_method>Non-Probability Sample</sampling_method>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
        Patients aged over 18 years with either small or advanced eumycetoma lesions with either&#xD;
        small or advanced actinmycetoma lesions with lesions of unknown causality&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
        &lt;18 years of age Inability to provide informed consent Any other reason that in the opinion&#xD;
        of the Investigator indicates the subject cannot comply with study protocol&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>Mohamed Osman, PhD</last_name>
    <role>Principal Investigator</role>
    <affiliation>University of Khartoum</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>University Hospital Soba</name>
      <address>
        <city>Khartoum</city>
        <zip>1111</zip>
        <country>Sudan</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Sudan</country>
  </location_countries>
  <verification_date>May 2020</verification_date>
  <study_first_submitted>May 19, 2020</study_first_submitted>
  <study_first_submitted_qc>May 20, 2020</study_first_submitted_qc>
  <study_first_posted type="Actual">May 26, 2020</study_first_posted>
  <last_update_submitted>May 20, 2020</last_update_submitted>
  <last_update_submitted_qc>May 20, 2020</last_update_submitted_qc>
  <last_update_posted type="Actual">May 26, 2020</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>University of Khartoum</investigator_affiliation>
    <investigator_full_name>Dr Mohamed Osman</investigator_full_name>
    <investigator_title>Principal Investigator</investigator_title>
  </responsible_party>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Mycetoma</mesh_term>
    <mesh_term>Granuloma</mesh_term>
  </condition_browse>
  <patient_data>
    <sharing_ipd>No</sharing_ipd>
  </patient_data>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT04401969
org study id: Mycetoma Study
nct id: NCT04401969
lead sponsor: 
collaborator: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
Mycetoma is the most neglected of the neglected tropical diseases. It is caused by certain
      fungi or bacteria. It is endemic in many tropical and subtropical regions and Sudan seems to
      be the mycetoma homeland. This chronic subcutaneous destructive and disabling inflammatory
      disease has many serious medical and socio-economic impacts on patients, community and health
      authorities. This work may suggest new therapeutic options for mycetoma that target the
      inflammatory pathogenic pathway and hence help in designing universal treatment options for
      mycetoma patients.

      Two overlapping aims were investigated in this project to advance our overall goals:

        1. Profiling the immune/inflammatory signatures in the tissue microenvironment of
           fungus-induced mycetoma lesions

        2. Profiling the immune/inflammatory signatures in the tissue microenvironment of
           bacteria-induced mycetoma lesions.
Mycetoma is a chronic, specific, subcutaneous granulomatous, progressive and disfiguring
      inflammatory disease. It is caused by true fungi or by certain bacteria and hence it is
      usually classified into eumycetoma and actinomycetoma respectively. Madurella mycetomatis is
      the commonest eumycetoma causative agent, while Streptomyces somaliensis and Nocardia
      brasiliensis are the common causative organisms for actinomycetoma. The triad of a painless
      subcutaneous mass, sinuses formation and purulent or sero-purulent discharge that contains
      grains is pathognomonic of mycetoma. The inflammatory subcutaneous granuloma usually spreads
      to involve the skin and the deep structures, resulting in destruction, deformity and loss of
      function, occasionally it can be fatal. The foot and hand are the most frequently affected
      sites seen in 82% of cases. In endemic areas, other parts of the body may be involved such as
      the knee, arm, leg, head and neck, thigh and perineum. No age is exempted in mycetoma;
      however, it occurs more frequently in young adult men in the age range 20-40 years and almost
      30% of reported patients were young students.

      The true incidence and prevalence of mycetoma world-wide is not precisely known. It is
      interesting to note that most of the reported mycetoma data are related to hospital patients
      with advanced disease. This is attributed to the nature of mycetoma which is usually
      painless, slowly progressive and the late presentation of the majority of patients due to the
      poor health education, lack of health facilities and financial constraints.

      The worldwide distribution of mycetoma varies widely. It is endemic in many tropical and
      subtropical regions and prevails in the mycetoma belt, which includes the countries of Sudan,
      Somalia, Senegal, India, Yemen, Mexico, Venezuela, Columbia, Argentina, and a few others. The
      African continent seems to have the highest burden and prevalence of the disease. It has also
      been extensively reported from India. However, mycetoma has been reported in many temperate
      regions as well. There are a few reports on mycetoma from the USA, Sri Lanka, Germany, Egypt,
      Turkey, Philippines, Japan, Lebanon, Thailand, Saudi Arabia, Tunisia and Iran.

      The proper treatment of mycetoma depends mainly on accurate diagnosis. It is essential to
      identify the causative organism to the species level and the current tests for that are the
      classical grains culture, surgical biopsy histopathological examination and various molecular
      techniques such as PCR. Various imaging techniques such as conventional radiology,
      ultrasonography, CT scan and MRI are in use to determine the disease extend. Most of these
      tests and techniques are invasive, expensive and of low sensitivity and specificity.
      Furthermore, they are not available in the mycetoma endemic regions and hence there is a
      desperate need forth easy to use, field-friendly test to identify the causative agent.

      The management of this distressing and devastating disease is disappointing. The treatment
      depends mainly on the aetiological agent, the site and extend of the disease. Until recently,
      the only available treatment for mycetoma was amputation or multiple mutilating disfiguring
      surgical excisions. Combined medical treatment in the form of antifungals for the eumycetoma
      and antibiotics and antimicrobial agents for actinomycetoma and various surgical excisions is
      the gold standard in mycetoma.

      Reports on medical treatment in eumycetoma are scarce and inadequate. Over the years and till
      now, the treatment of eumycetoma was based on personal clinical experience and on the results
      of sporadic case reports, rather than controlled clinical trials. In general, massive
      surgical excisions or amputation of affected part is the treatment of choice for eumycetoma.
      Various antifungal agents have been tried with little success. This is perhaps surprising, as
      the eumycetoma causative agents are low-grade infective organisms and their eradication
      should be readily achieved by the administration of antifungal drugs. Generally,
      actinomycetoma is amenable to medical treatment with antibiotics and other chemotherapeutic
      agents. Combined drug therapy is always preferred to a single drug to avoid drug resistance
      and for disease eradication.

      Medical treatment for both types of mycetoma must continue until the patient is clinically,
      radiologically, ultrasonically and cytologically cured. Recurrence is more common after an
      incomplete or irregular course of medical treatment. With patient non-compliance, there is a
      good chance for the organism to develop drug resistance.

      The study was conducted at the Mycetoma clinic at the Mycetoma Research Centre (MRC),
      Khartoum Sudan. Patients were enrolled into the study after written informed consent was
      obtained in line with the Declaration of Helsinki.

      Patients were categorized into three groups;

        -  Patients with eumycetoma lesions (n=10)

        -  Patients with actinomycetoma lesions (n=12)

        -  Patients with lesions of unknown causality (n=6)

      Formalin fixation and paraffin embedding was performed at the MRC according to standard
      procedures.

      Fine needle aspirates (FNA) was collected for flow cytometry at the same time and at the same
      location of the lesion in the body.

      Aspirates were frozen at -80C for future analysis. Concurrently, 15 ml of blood was taken
      from each patient for immunological function assays.

      Peripheral blood mononuclear cells were prepared using standard protocols and stored in
      liquid nitrogen till required.

      5 ml of blood was collected in Paxgene tubes for transcriptomics analysis.

      Immunohistochemistry Immunohistochemistry was performed at University of York, UK. Formalin
      fixed paraffin embedded (FFPE) sections were analysed using the 700 gene Nanostring PanCancer
      Immune Cell profiling panel to obtain a high level view of the immune/inflammatory signature.

      Serial sections were subjected to highly multiplexed antibody staining using the Nanostring
      Digital Spatial Profiling system to obtain a comprehensive and spatially resolved insights
      into lesion microenvironment.

      Candidate pan-mycetoma targets identified by these approaches were confirmed using
      immunofluorescent antibodies and RNA-fluorescent in situ hybridisation.

      All data was recorded as digitised whole slide images for publication and archiving.

      Antigen specific T cell responses T cells responses analysis were performed at Institute for
      Endemic Diseases, University of Khartoum.

      Peripheral blood mononuclear cells (PBMCs) from patients and age and sex matched healthy
      control from endemic area were stimulated for 7 days with fungus and bacterial lysates. IFN,
      IL-17, IL-4 and IL-10 responses were determined by ELISPOT assay.

      Flow cytometry on FNBs were performed with panels of antibodies to evaluate T cell and
      myeloid cell phenotype.

      Whole blood transcriptomics Blood were collected into Paxgene and stored at - 80c. RNA were
      extracted from stored samples Full whole blood transcriptomic data was obtained by RNA-Seq.

      Cytokine measurements in mycetoma aspirates were undertaken using commercially available
      ELISA kits.
observational model: Case-Only
time perspective: Cross-Sectional
measure: immune cell phenotypes
time frame: 24 months
description: detection of immune cell phenotypes in mycetoma lesions
measure: antigen-specific t-cell responses
time frame: 24 months
description: detection of t cell and myeloid cell phenotype in peripheral blood
arm group label: Patients with eumycetoma lesions
description: Patients with eumycetoma lesions
arm group label: Patients with actinomycetoma lesions
description: Patients with actinomycetoma lesions
arm group label: Patients with lesions of unknown causality
description: Patients with lesions of unknown causality
Needle biopsy samples from mycetoma lesions

      Fine needle aspirates from the matching mycetoma lesion

      Whole blood for RNA analysis
study pop: 
sampling method: Non-Probability Sample
criteria: 
gender: All
minimum age: 18 Years
maximum age: N/A
healthy volunteers: No
last name: Mohamed Osman, PhD
role: Principal Investigator
affiliation: University of Khartoum
facility: 
country: Sudan
responsible party type: Principal Investigator
investigator affiliation: University of Khartoum
investigator full name: Dr Mohamed Osman
investigator title: Principal Investigator
mesh term: Mycetoma
mesh term: Granuloma
sharing ipd: No