Conidiobolus coronatus granuloma of the right inferior turbinate: A rare presentation

Fungal infections are common in tropical countries such as India. Very few clinical cases caused by the Entomophthorales Zygomycetes have been reported. Rhinofacial infection is a rare form of zygomycosis in humans, and only limited information regarding optimal treatment is available. We report here a rare case of rhinofacial Conidiobolus coronatus infection in a previously healthy 18-year-old man who presented with a fungal granuloma of the right inferior turbinate and face. Diagnosis was confirmed by microbiologic culture from a tissue biopsy. The infection was successfully treated with surgery and itraconazole therapy for 12 months. The clinical presentation and treatment of this rare, chronic, indolent form of fungal infection are highlighted in this article.

Nasal vestibulitis due to targeted therapies in cancer patients

BACKGROUND AND PURPOSE

Cancer patients treated with targeted therapies (e.g., epidermal growth factor receptor inhibitors) are susceptible to dermatologic adverse events (AEs) including secondary skin infections. Whereas infections such as paronychia and cellulitis have been reported, nasal vestibulitis (NV) has not been described with the use of these agents. The aim of our study was to characterize NV in cancer patients treated with targeted therapies.

METHODS

We utilized a retrospective chart review of cancer patients who had been referred to dermatology and were diagnosed with NV. We recorded data including demographics, referral reason, underlying malignancy, targeted anticancer regimen, NV treatment, and nasal bacterial culture results.

RESULTS

One Hundred Fifteen patients were included in the analysis, of which 13 % experienced multiple NV episodes. Skin rash was the most common reason (90 %) for a dermatology referral. The most common underlying malignancies were lung (43 %), breast (19 %), and colorectal (10 %) cancer. Sixty-eight percent of patients had been treated with an EGFRI-based regimen. Nasal cultures were obtained in 60 % of episodes, of which 94 % were positive for one or more organisms. Staphylococcus aureus was the most commonly isolated organism [methicillin-sensitive S. aureus 43 %; methicillin-resistant S. aureus 3 %].

CONCLUSIONS

We report the incidence and characteristics of an unreported, yet frequent dermatologic condition in cancer patients treated with targeted therapies. These findings provide the basis for additional studies to describe the incidence, treatment, and consequences of this event. A better understanding of NV would mitigate its impact on patients' quality of life and risk for additional dermatologic AEs.

Periorbital pain induced by the concha bullosa fungus ball: a case report

Concha bullosa is characterized by pneumatization of the middle turbinate and is one of the most common variations of the sinonasal anatomy. It is most often asymptomatic. A fungus ball in the concha bullosa is extremely rare, with only two reported cases in the English literature. This article describes a patient with such a fungus ball in the concha bullosa that caused right periorbital pain, specifically in the right medial canthal area, similar to mucosal contact point headache.

[Rhino-orbito-cerebral mucormycosis: report of 9 cases]

OBJECTIVE

To present the clinical characteristics and combination therapy of rhino-orbito-cerebral mucormycosis.

METHODS

The clinical data of 9 patients with rhino-orbito-cerebral mucormycosis treated between January 2008 and January 2013 were analyzed retrospectively. The clinical features, diagnosis, pathological characteristics, surgical technique and combination therapy were summarized. All the patients were treated with nasal endoscopic surgery and combined drug therapy.

RESULTS

Nine patients were under the state of systemic immunosuppression. Two patients died of intracranial infection. One patient with the symptom of headache was first alleviated after treatment, with visual acuity recovered partially, but this patient died 4 months later due to recurrence of mucormycosis and intracranial infection. Two patients with headache recovered after treatment, the visual acuity recovered to the hand movement, endoscopic examination of surgical cavity was clean and epithelialized, with no recurrence, still alive 5 years up to now. The symptom of headache in another 4 patients disappeared after treatment, visual acuity improved significantly, endoscopic surgical cavity was clean, follow-up with no recurrence, survived more than 2 years, and were still in the treatment of primary disease.

CONCLUSION

Rhino-orbito-cerebral mucormycosis is a serious chance infectious disease under the state of systemic immunosuppression, the development is rapid and the mortality rate is high, early diagnosis and combined treatment with nasal endoscopic surgery is necessary.

[Rhinofacial conidiobolomycosis associated with cervical, thoracic and brachial localizations: one clinical case in Nigeria]

We report here the clinical case of a Nigerian adult patient who received medical care during October 2010, at the Center for Diagnosis and Treatment of Buruli ulcer in Pobè (Benin). He presented a massive facial tumor associated with several subcutaneous (cervical, thoracic and upper limbs) nodules, evolving since several years. Tissue samples collected at Pobè medical center were addressed to the mycology and histology laboratories of Angers University Hospital (France), according to the medical exchange agreement between the two institutions about the diagnosis and treatment of Buruli ulcer disease. Histological examination showed a Splendore-Hoeppli phenomenon, consisting of a granulomatous reaction made of eosinophilic polynuclear cells surrounding rare, large and irregular, non-septate hyphae. A filamentous fungus was isolated by cultivation of the clinical samples, which was identified as Conidiobolus coronatus. The patient was treated orally with daily doses of ketoconazole (400 mg per day). After 4 months of treatment, a marked regression of the facial lesion was obtained. A first constructive facial surgery was achieved, but the patient did not attend the second step. This case report allows us to remind the mycological diagnosis of this exotic mycosis, but also to emphasize the main difficulties encountered in medical management in the developing countries.

Oronasal blastomycosis in a golden retriever

Blastomycosis is one of the most common systemic fungal infections in dogs in North America Pulmonary manifestations are most common; localized disease is rare. A case of localized oronasal blastomycosis mimicking oral neoplasia is described. Long-term therapy with itraconazole resulted in clinical cure.

Lupus Vulgaris Erythematoides: report of a patient initially misdiagnosed as dermatitis

A small percentage of patients with tuberculosis present with cutaneous findings, which may be difficult to diagnose. We present a patient diagnosed with a rare, non-scarring form of cutaneous tuberculosis (CTB), classically termed as lupus vulgaris erythematoides.

[A case of rhinolith and actinomycosis]

The patient presented with right nasal obstruction, purulent secretion in nasal meatus and dull headache for 3 years. A dark brown mass, irregular in shape, surface roughness and purulent secretion adherent, was seen in the nose, touched as coal tar stone. CT examination showed high density in the right nasal meatus. Postoperative pathological examination proved to be rhinolith and actinomycosis.

Spontaneous cerebrospinal fluid rhinorrhea with pneumocephalus: an unusual manifestation of nasal tuberculosis

An unusual case of spontaneous cerebrospinal fluid (CSF) rhinorrhea with a pneumocephalus is described in a middle-aged woman who presented with a watery nasal discharge for 1 week and headache, vomiting, and fever for 1 day. The neurological examination revealed meningeal signs and bilateral papilledema. The CSF picture suggested pyogenic meningitis, and computed tomography of the brain revealed pneumocephalus. Diagnostic nasal endoscopy showed outpouching of the dura from the left olfactory cleft with a CSF leak and granular nasal mucosa. The defect was repaired surgically, and a biopsy of that area revealed granulomatous changes suggestive of tuberculosis. The patient recovered completely with standard four-drug antitubercular therapy. To our knowledge spontaneous CSF rhinorrhea with pneumocephalus occurring secondary to nasal tuberculosis has not been previously reported.

Methicillin-resistant Staphylococcus aureus (MRSA) on the skin of long-term hospitalised horses

Given the significance of methicillin-resistant Staphylococcus aureus (MRSA) infections for both horses and staff in equine veterinary hospitals, protocols are required to minimise the risk of nosocomial transmission, including the screening of the skin and nasal chambers of equine patients for evidence of infection. The objective of this study was to clarify the potential existence and extent of MRSA on the skin of horses requiring long-term hospitalisation (≥ 6 months). Thirty such horses were sampled at eight different locations on their skin and from their nasal chambers. MRSA was isolated from 12 animals (40%), with all sample sites testing positive on at least one occasion. Organisms were most frequently detected in the nasal chambers (relative sensitivity, 83.3%; 34.5% positive horses; isolation rate 33.3%). Skin presence was found in 30% of animals with the highest isolation rates found at the carpus (16.7%), neck, withers and croup (13.3% each). To achieve a relative screening sensitivity of >90%, at least one skin site was required in addition to nasal sampling. This evidence of skin as well as nasal reservoirs of MRSA in long-term hospitalised horses should facilitate the design of effective screening and containment protocols.

[Mucormycosis. An emergent mycosis]

Mucormycosis is an opportunistic infection caused by fungi of the order Mucorales. It is characterized by rapid progression and high morbidity and mortality in the absence of early diagnosis and prompt treatment. It was an infrequent disease, but in recent years, its incidence appears to have increased. The aim of this paper is to report the cases of mucormycosis diagnosed from 1982 to 2010 at the Hospital de Clinicas José de San Martín, University of Buenos Aires. We diagnosed 10 cases of mucormycosis; the first three between 1982 and 2004 and the last 7 between 2005 and 2010. The incidence from 1980 to 2004 was 0.13 patient-years and the frequency 0.1/10 000 discharges (95% CI 0.00- 0.3). In the period 2005 to 2010, the incidence was 0.86 patients per year with 1.1/10 000 discharges (95% CI 0.5-2.4). There was a pulmonary mucormycosis case (in a patient treated with corticosteroids) and nine rhinocerebral cases, two in neutropenic and seven in diabetic patients. The diagnosis was made by observation of cenocytic hyphae in 10/10 patients. Mucorales were recovered in 8/9 cultures (5 Rhizopus spp and 3 Mucor spp.). In one case diagnosis of pulmonary mucormycosis was made post-mortem. Nine patients were treated with amphotericin B deoxycholate (in 3 patients supplemented with liposomal amphotericin B) and surgery. Three patients underwent hyperbaric chamber. Seven patients had favorable outcome. In conclusion, mucormycosis is a rare disease, but its incidence has increased over the past five years. A good evolution of the patients is linked to early diagnosis and treatment.

Management and outcomes of three cases of rhinocerebral mucormycosis

Mucormycosis is a rare opportunistic infection caused by fungi belonging to Mucorales order. The infection usually starts in the middle or inferior nasal meatus and then spreads to the paranasal sinuses and the orbit. Then it reaches the brain through the ethmoid and the orbit apex and can lead to lethargy, paralysis, and death. The majority of cases of rhinocerebral mucormycosis are diagnosed in patients with immunologic and metabolic disorders. Early diagnosis is fundamental, and so is medical therapy with amphotericin B along with surgical toilet of the compromised tissues. This article presents and discusses the management of 3 cases of rhinocerebral mucormycosis with different onsets, progressions, and outcomes.

[Mucormycosis: retrospective evaluation of 12 cases]

Mucormycosis is a rare and often fatal invasive fungal infection. Disseminated or pulmonary forms are common in patients with immune deficiency while rhinocerebral form is common in diabetes mellitus. The aim of this study was to evaluate retrospectively the adult mucormycosis cases which were followed up in our hospital between 2007-2010. The cases were evaluated in terms of demographic characteristics, underlying diseases, laboratory, clinical and treatment results. A total of 12 mucormycosis cases (6 were male; age range: 18-74 years; mean age: 50.83 ± 18.27 years) were evaluated. Ten of the 12 cases had definitive diagnosis of invasive fungal infection according to EORTC/MSG (European Organization for Research and Treatment of Cancer/Mycoses Study Group) criteria whereas two had possible mucormycosis. Six cases had rhinoorbital, four had rhinocerabral, one had pulmonary and one had rhinocerebral and pulmonary mucormycosis. Fever (n= 10; 83%), edema in face (n= 8; 67%) and eyes (n= 6; 50%) were the most common symptoms and findings. Mycologic culture was performed in ten cases and was found positive in five cases (four cases had Rhizopus spp. one case had Mucor). In two cases direct microscopy revealed mycelium but culture did not yield any pathogen. Two cases had concomitant Aspergillus spp. growth. Overall mortality rate was determined as 50% (6/12). All of the cases received antifungal therapy (liposomal amphotericin B and posaconazole or itraconazole), however, surgical intervention was applied to five cases. Mean duration of antifungal treatment was 60.8 ± 47.4 days. Mortality rate was lower in cases who received concomitant surgical therapy, but the difference was not found statistically significant (2/5 vs. 4/7, p> 0.05). Hematologic diseases (n= 6) and diabetes mellitus (n= 3) were the most common underlying diseases in mucormycosis cases. Voriconazole prophylaxis applied to three cases with hematologic diseases was detected as a risk factor. Development of mucormycosis in those cases who were under voriconazole prophylaxis, deserves attention. Since this is the largest 3-years series of adult mucormycosis cases reported from a single center and includes the first cases treated with posaconazole, the results of this evaluation may aid to the management of patients with mucormycosis.

Prevalence of Staphylococcus aureus and lack of its lytic bacteriophages in the anterior nares of patients and healthcare workers at a rural clinic

BACKGROUND

Nearly 30% of people in the United States are colonized with Staphylococcus aureus and 1% to 2% with methicillin-resistant Staphylococcus aureus (MRSA) in the anterior nares. However, it is not known if lytic bacteriophages against S. aureus are present in the anterior nares, and if they are, what the prevalence rate is, or if they interfere with S. aureus colonization. The aim of this study was to determine the prevalence of nasal carriage of S. aureus and MRSA and to screen for S. aureus lytic bacteriophages in healthcare environment workers and ambulatory patients.

METHODS

We enrolled 202 individuals into this study. The anterior nares were swabbed to isolate S. aureus, MRSA, and any lytic S. aureus bacteriophages that may be present. Putative S. aureus colonies on blood agar plates were identified using gram stain, catalase and coagulase tests, and confirmed by S. aureus-specific PCR. Presence of staphylococcal lytic bacteriophages were screened by a plaque assay technique using a methicillin-sensitive reference S. aureus strain ATCC 29213.

RESULTS

Of the 49 (24%) individuals who screened positive for S. aureus, two (1%) were positive for MRSA. None of the samples were positive for lytic bacteriophages against S. aureus. Subgroup analysis found no significant difference in the prevalence of S. aureus in the house staff compared to other healthcare environment workers or ambulatory patients of the clinic. Similarly, no significant difference in colonization was noted across the population with respect to age, sex, body mass index, or presence of diabetes mellitus.

CONCLUSION

The prevalence of nasal carriage of S. aureus and MRSA in the studied population was 24% and 1%, respectively, similar to the rate of prevalence in the United States. The study also showed that the anterior nares do not seem to harbor lytic bacteriophages against S. aureus.

Rhinocerebral zygomycosis in Pakistan: clinical spectrum, management, and outcome

OBJECTIVE

To study the disease spectrum and salient management features of 36 patients with histopathologically-confirmed rhinocerebral zygomycosis seen at our academic center over a 16-year period.

METHODS

Retrospective review of patients admitted to the Aga Khan University Hospital in Karachi, Pakistan from January 1991 to December 2006 with histopathologically-confirmed zygomycosis of the head and neck.

RESULTS

Mean patient age was 40 +/- 5.0 years (range, 34-63 years), and 23 (64%) patients were male. Thirty-two (89%) patients were referred from clinical services other than otolaryngology. Underlying predisposing conditions included diabetes mellitus (21 patients), haematologic diseases (9), and renal failure (6). Twenty (55%) patients had limited sinonasal disease, ten (28%) had orbital involvement, and six (17%) had intracranial extension. All patients underwent rigid nasal endoscopy and biopsy, and black necrotic tissue was seen in 22 (61%) instances warranting endoscopic or open surgical debridement. Four of 6 patients undergoing open surgery required orbital exenteration. Overall patient survival was 56% (20/36 patients). Diabetic patients had improved survival (17/21, or 81%) compared to patients with haematologic disorders (3/9, or 33%) (p = 0.001). All six patients with intracerebral disease died. Eighteen of the 22 (82%) patients treated with surgery plus amphotericin B survived vs. two of 14 (14%) receiving amphotericin B alone (p < 0.001).

CONCLUSIONS

In rhinocerebral zygomycosis, an aggressive, multidisciplinary, diagnostic and therapeutic approach that utilizes CT or MRI staging, and combines endoscopic or open surgical debridement with amphotericin B-based antifungal therapy offers the best chance of recovery.

Rhino-cerebral zygomycosis after allogeneic transplant: case report and literature review

The proportion of patients with hematological malignancies (HM) who develop rare invasive fungal infections (IFI) has increased worldwide over the past few decades. Zygomycosis is an opportunistic fungal infection, which begins in the nose and paranasal sinuses due to inhalation of fungal spores. Rhino-cerebral zygomycosis is the most common form of the disease, it typically develops in diabetic or immunocompromised patients and presents as an acute fulminate infection, which is often lethal. We report a case of rhino-cerebral zygomycosis in an allotransplanted patient to emphasize early diagnosis and treatment of this potentially fatal fungal infection. We discuss different risk factors, specific diagnosis procedures and review the current concepts in management of zygomycosis.

Rhinocerebral mucormycosis: five cases and a literature review

OBJECTIVE

In this retrospective study, we describe our experience in the diagnosis and management of rhinocerebral mucormycosis (RCM), a rapidly lethal fungal infection.

METHODOLOGY

Between 1997 and 2007, five patients hospitalized for suspicion of RCM. Computed tomography was performed in all cases, and diagnosis was confirmed after anatomopathological or mycological examination. All patients underwent medical and surgical treatment. Follow-up was clinical and radiological with a mean period of 17 months.

RESULTS

All patients were diabetic. Exophthalmia, rhinorrhea, and ophthalmoplegia were the most frequent symptoms observed. One patient had loss of visual acuity and another exhibited peripheral facial palsy. One patient had extensive hemifacial cutaneous necrosis. Nasal endoscopy revealed black necrotic lesions in one case, and another patient had a tumefaction localised in the left middle meatus. Necrotic lesions were most often found in the orbit, the maxillary and the ethmoidal sinuses on computed tomography (four cases for each site). One patient had thrombophlebitis of the cavernous sinus, and another had an intracranial extension. All patients were administered ordinary insulin and intravenous amphotericin B. Surgical debridement of the nasal cavity and the involved sinuses was performed through lateral rhinotomy (four cases) or endoscopy (one case). Unilateral orbital exenteration was associated in two cases. Progression was favourable in four cases; one patient died from sepsis despite aggressive treatment.

CONCLUSION

Early diagnosis is crucial for the management of RCM. Treatment of underlying disorders, use of intravenous amphotericin B, and aggressive surgical intervention are key in reducing morbidity and mortality rates.

Primary tuberculosis of nose with intracranial extension: a rare presentation

Tuberculosis continues to be a major public health problem. This disease has varying presenting features. We here present a case of primary tuberculosis of the nose with intracranial extension, a very rare presenting feature of tuberculosis.

A nodulo-ulcerative lesion on the nose

Lupus vulgaris (LV) is a chronic, progressive, and potentially destructive form of cutaneous tuberculosis commonly seen in previously sensitized individuals with moderate to high immunity. We present a case of LV located on the nose of an 84-year-old female patient, discuss the diagnosis and treatment modalities, and emphasize the importance of having a high index of suspicion for this condition.

Histoplasmosis in the nasal septum without pulmonary involvement in a patient with acquired immunodeficiency syndrome: case report and literature review

CONTEXT

Histoplasmosis is a fungal disease caused by inhaling spores of the fungus Histoplasma capsulatum. The spores can be found in soil contaminated with bird, bat or chicken feces. Histoplasmosis occurs worldwide and is one of the most common pulmonary and systemic mycoses.

CASE REPORT

We report here the case of a 37-year-old man with acquired immune deficiency syndrome and histoplasmosis in the nasal septum, without pulmonary involvement, that evolved rapidly to disseminated infection, multiple organ failure and death.