Mucocutaneous nasal histoplasmosis in an immunocompetent young adult

A case of mucocutaneous nasal histoplasmosis in an immunocompetent host is described below. A 30-year-old male had a broadened nose with swelling and repeated blockage of nasal passages for the past six months. Diagnosis was made on the basis of histological demonstration of characteristic yeast cells of Histoplasma capsulatum var. capsulatum occurring within histiocytes and extracellularly in stained smears of fine needle aspirates and biopsy from the lesions in ala of the nose and perioral region. The patient showed appreciable regression of lesions after three weeks of itraconazole therapy but was not available for re-assessment.

[Primary nasal tuberculosis: a case report]

We report a case of a 36 year old woman who presented a chronic rhinitis and a hypertrophy of the inferior turbinates. Primary nasal tuberculosis was discovered by chance after the inferior turbinectomy. Primary nasal tuberculosis is very rare and is more frequent in women. Symptomatology is often unilateral with nasal obstruction, anterior rhinorrhea or epistaxis. The clinical examination may discover ulceration or a polyp located generally in the nasal septum or the inferior turbinate. Diagnosis relies on the anatomopathologic and bacteriological examinations. The treatment is mainly medical based on antituberculosis drugs. In the light of this case report, a review of the literature was made.

Rhinocerebral mucormycosis with orbital and intracranial extension: a case report and review of optimum management

Rhinocerebral mucormycosis is a devastating, rapidly progressive and often fatal opportunistic fungal infection predominantly affecting individuals with underlying metabolic and/or immunological compromise. Intracranial extension of the disease has invariably been associated with mortality.We present a review of optimum management of rhinocerebral mucormycosis and a case report of sinonasal mucormycosis with intracranial and orbital extension which was treated successfully with a combination of systemic liposomal amphotericin B therapy and wide surgical debridement.

Cytologic identification of immature endospores in a dog with rhinosporidiosis

An 8-year-old, intact, male Labrador Retriever was presented to the Boren Veterinary Medical Teaching Hospital at Oklahoma State University with a 2-month history of severe sneezing episodes that resulted in epistaxis and bilateral sanguineous discharge. Rhinoscopy revealed a small polypoid mass, and specimens were obtained for histopathology. Microscopic examination of formalin-fixed tissue specimens revealed organisms consistent with Rhinosporidium seeberi. The mass was surgically excised and impression smears were made for cytology examination. Smears revealed high numbers of endospores, typical of those previously described for R seeberi. In addition, numerous smaller structures, presumed to be immature endospores, were noted. The immature endospores were morphologically distinct from mature endospores and have not been described previously. Recognition of immature forms of Rhinosporidium may help prevent misidentification of the organism or misdiagnosis of a dual infection.

Unusual Corynebacterium mucifaciens isolated from ear and nasal specimens

OBJECTIVE

Corynebacterium mucifaciens was first proposed as a novel Corynebacterium species in 1997. This report describes our experience with the unexpectedly frequent isolation of C mucifaciens.

STUDY DESIGN

By using agar supplemented with several antibiotics, microbiological studies were performed on specimens collected from the ear and nose.

SETTING

A primary and secondary referral hospital.

RESULTS

The organisms grew slowly. Five strains of C mucifaciens were found in specimens of middle ear effusion (MEE) from patients with otitis media with effusion (OME), and four strains were isolated from the nasal polyps and nasal discharge of patients with chronic sinusitis (CRS).

CONCLUSIONS

C mucifaciens was isolated from nine otorhinological specimens.

SIGNIFICANCE

This is the first report about the isolation of C mucifaciens from MEE, nasal polyps, and nasal discharge. Although its pathogenetic role is unknown, the characteristics of this microorganism might make it a potential cause of OME and/or CRS, so further studies are necessary.

EBM RATING

C-4.

Methicillin resistant Staphylococcus aureus: is it a problem for nasal surgery?

Methicillin resistant Staphylococcus aureus (MRSA) is becoming ever more prevalent in the UK, and the proportion of MRSA to methicillin sensitive Staphylococcus aureus (MSSA) seems to be increasing. New strains of MRSA are ever developing resistance to antibiotic treatment, increasing morbidity and mortality of infection. Staphylococcus aureus is part of the normal flora of the nose, and MRSA colonizes the nose in infection. However, nasal surgery is rarely complicated by staphylococcal infections, and MRSA infection following nasal surgery is rare. The authors present a literature review of MRSA infection, its relation to the nasal cavity, and infection following nasal surgery.

Sinoorbital mucormycosis due to Apophysomyces elegans in immunocompetent individuals--an increasing trend

OBJECTIVE

Mucormycosis is a fatal infection of the immunocompromised individuals. Apophysomyces elegans is an unusual pathogen causing mucormycosis. It is unusual to affect the healthy individuals. We report 5 such cases of infection caused by A elegans in immunocompetent individuals.

STUDY DESIGN

Retrospective case review conducted at a tertiary referral center.

METHODS

From 1999 to 2004, 5 cases of mucormycosis caused by A elegans were managed in otherwise healthy patients. All of them were treated with surgery. Clinical presentation, imaging studies, mycological findings, operative findings at surgery, and postoperative results were evaluated. A review of literature about mucormycosis caused by A elegans infecting otherwise healthy patients in orbit, nose, and paranasal sinuses has been done.

RESULTS

All had no previous history of trauma or any invasive procedure. All of them underwent surgical treatment. Histopathological examination showed broad, sparsely aseptate, thin-walled hyphae and angioinvasion with thrombosis. Fungal culture revealed A elegans.

CONCLUSION

Mucormycosis must be considered in the differential diagnosis of any severe acute headache, sinusitis, or orbital cellulites not only in the immunocompromised patients but also in the absence of any underlying disease. Successful treatment requires early debridement and systemic antifungal treatment with injection of amphotericin B.

Disseminated rhinosporidiosis - an unusual presentation with pulmonary involvement

BACKGROUND AND AIM

Rhinosporidiosis is a chronic granulomatous disease that commonly affects the nasal and nasopharyngeal mucosa. It rarely presents as disseminated disease.

CASE REPORT

We describe a rare case of a patient who had undergone treatment for recurrent nasal rhinosporidiosis and who presented with multiple subcutaneous swellings and pulmonary lesions.

[Pathologic diagnosis of early syphilis in nasal cavity and oropharynx]

OBJECTIVE

To study the pathologic changes in nasal and oropharyngeal mucosa caused by treponema pallidum (TP) infection.

METHODS

Twenty-five cases of nasal and oropharyngeal syphilis were retrieved from the archival files of Department of Pathology of Beijing Tong Ren Hospital collected during the period from June 1996 to September 2005. The hematoxylin and eosin-stained slides were reviewed. Histochemical study using modified Warthin-Starry stain and immunohistochemical study using polyclonal antibody for TP were carried out. The diagnosis of early syphilis was confirmed by rapid plasma regain (RPR) and TP hemagglutination (TPHA) tests.

RESULTS

Among the 25 cases studied, 20 showed neutrophil infiltration, microabscess formation and plasma cell infiltration in the lamina propria. Endothelial swelling of small blood vessels and syphilitic vasculitis was also seen. Tonsillar ulcers associated with abundant plasma cells, lymphocytes and histiocytes were noted in 14 cases. One of which demonstrated florid reactive lymphoid proliferation, with transforming lymphoid cells of various stages identified. Pseudoneoplastic squamous cell proliferation was seen in one case. Spirochetes were detected by modified Warthin-Starry stain in mucosal microabscesses and squamous epithelium in 20 cases, around small blood vessels in 5 cases, and on the surface of tonsillar ulcers in 14 cases. Abundant TP were also found in smears of exudates in 6 cases. TP antigen was detected in 4 cases by immunohistochemical staining. All the 25 cases studied were RPR (1:8 to 128) and TPHA-positive.

CONCLUSIONS

Early syphilis involving nasal cavity and oropharynx has distinctive pathologic features. Detailed histologic examination, together with modified Warthin-Starry stain for demonstration of spirochetes, is important to obtain a correct diagnosis.

Sino-nasal bony and cartilaginous destruction associated with cocaine abuse, S. aureus and antineutrophil cytoplasmic antibodies

Three male patients aged 29, 30 and 34 years and a 36-year-old female are reported with nasal septum perforation and a history of cocaine abuse. Two of the patients also had a perforation of the hard palate. In all four, antineutrophil cytoplasmic antibodies (ANCA) were found. One had a cytoplasmic immunofluorescence-staining pattern (c-ANCA), the other three showed a perinuclear staining pattern (p-ANCA). Furthermore, all patients were found to be nasal carriers of S. aureus. We hypothesise that tissue damage to the nasal and palatal area in patients using cocaine may partly be mediated by the presence of ANCA antibodies. Furthermore, we speculate that S. aureus facilitates the development of these ANCA antibodies.

[Rhinocerebral mucormycosis in four diabetics]

Mucormycosis is caused by a zygomycetes fungus in a vascular location. This fungus is a saprophytic organism which can become pathogenic in specific conditions, particularly in patients with diabetes mellitus. A rhinocerebral localization is common, leading to often fatal devastating sinusitis. Positive diagnosis requires histological proof with characteristic hyphal tissue invasion. Frozen section is essential for diagnosis and management of rhinocerebral mucormycosis.

MATERIAL AND METHODS

We report four cases of rhinocerebral mucormycosis in diabetic patients, two men and two women, mean age 51 years.

RESULTS

Histological examination showed characteristic hyphae in a vascular localization. Treatment was systemic antifungal therapy with amphotericin B and debridement of necrotic tissue. Three patients recovered completely. One died.

CONCLUSION

Rhinocerebral mucormycosis is a rare fungal infection with very poor prognosis. The aim of this study was to report the clinical and pathological features of rhinocerebral mucormycosis and to evaluate the contribution of frozen section for diagnosis and management.

Rhino-orbitocerebral mucormycosis caused by Apophysomyces elegans

Rhino-orbitocerebral mucormycosis (ROCM) caused by more common zygomycetes (e.g., Mucor) is known to cause rapidly fatal infections in immunocompromised patients. Apophysomyces elegans is an emerging zygomycete that has been reported to cause invasive cutaneous and rhino-orbitocerebral infections in immunocompetent individuals. Limited data exist describing the syndrome of ROCM caused by A. elegans. We describe a recent case and performed a comprehensive literature review to delineate the clinical characteristics of ROCM caused by A. elegans. Our case is a 50-year-old man with diabetes mellitus who presented with facial pain and right eye proptosis. Endoscopic sinus sampling revealed A. elegans. He was treated with liposomal amphotericin B and multiple debridements, with no disease on 1.5-year follow-up examination. Seven cases were identified on literature review, including the present case. Most patients (86%) were male, with a mean age of 40 years. Most patients (71%) did not have predisposing medical conditions. Three patients had predisposing head trauma. All presented with facial and/or periorbital pain. All had magnetic resonance imaging or computed tomography of the head showing intraorbital and/or sinus inflammation. Diagnosis was confirmed by histopathology and deep tissue culture in all cases. All patients required eye exenteration and extensive surgical debridement, in addition to intravenous amphotericin B. Six of the seven patients (86%) recovered. ROCM caused by A. elegans is rarely reported in the literature. Most such infections occurred in immunocompetent patients, often after facial trauma. Survival in ROCM caused by A. elegans is favorable in reported cases, with prompt surgical debridement and antifungal therapy.

Results of rhinoscopy alone or in conjunction with sinuscopy in dogs with aspergillosis: 46 cases (2001-2004)

OBJECTIVE

To determine results of diagnostic testing, including detection of nasal or frontal sinus fungal plaques, in dogs with nasal aspergillosis.

DESIGN

Retrospective case series.

ANIMALS

46 dogs with nasal aspergillosis.

PROCEDURES

Medical records were reviewed for information on computed tomographic findings; rhinoscopic findings, including whether fungal plaques were seen in the nasal cavity; results of frontal sinus trephination and sinuscopy, including whether fungal plaques were seen in the frontal sinus; and results of histologic examination of biopsy specimens.

RESULTS

In 38 (83%) dogs, fungal plaques were seen in the nasal cavity during rhinoscopy, whereas in the remaining 8 (17%), fungal plaques were not seen in the nasal cavity but were seen in the frontal sinus. Duration of clinical signs, proportions of dogs in which the referring veterinarian had performed a nasal examination prior to referral, proportions of dogs with computed tomographic evidence of nasal cavity cavitation or sinus involvement, and proportions of dogs with rhinoscopic evidence of destructive rhinitis were not significantly different between dogs with nasal fungal plaques and dogs with fungal plaques only in the frontal sinus.

CONCLUSIONS AND CLINICAL RELEVANCE

Results confirm that frontal sinus involvement is common in dogs with nasal aspergillosis and suggest that frontal sinus trephination and sinuscopy may aid in the diagnosis of aspergillosis in dogs, particularly dogs with rhinoscopic evidence of destructive rhinitis and computed tomographic evidence of sinus involvement that lack detectable fungal plaques in the nasal cavity.

[Facial entomophtoromycosis: à propos of a case]

We report one case of rare facial entomophtoromycosis which occured in a young male patient of 16 years of age, in Cameroon. The clinical presentation was a central mass of the face. We show the interest of the diagnosis of this rare fungal infection through biopsy and its medical treatment.

Rhino-orbito-cerebral mucormycosis: a treatment dilemma

A case of rhino-orbito-cerebral mucormycosis is presented showing its aggressive nature and progression of disease. The typical clinical features, neuroimaging and histological findings are highlighted in this report. Amphotericin B and surgical debridement remain the mainstay of treatment. However, associated co-morbidities need to be addressed.

[Rhinofacial entomophthoromycosis. About two new cases in Mayotte]

Conidiobolus entomophthoromycosis is a rare mycosis due to an ubiquitary telluric fungus. Although the organism is found around the world, it is more concentrated in warm, wet climates. Cases have been described in West Africa, Australia, South America and India. Conidiobolus spp was also to be found in animal like horse. The transmission mode of Conidiobolus has not been established but probably occurs via inhalation of fungal spores covering the nasal mucous membrane or from a minor trauma such as an insect bite. The clinical syndromes include intranasal tumour, nasal obstruction, broadening of the nose bridge, paranasal sinuses, cheeks and upper lip. Diagnostic is made by demonstrating distinctive non-septate hyphea with surrounding eosinophilic sleeve (Splendore-Hoeppli phenomenom) in tissue sections. We report here two cases contracted in Comoro Islands. The first one was a 26 year-old man treated by amphotericin B during six weeks and then by itraconazole, with a clear improvement. The second one was a 37 year-old woman. She has been treated by amphotericin B, subsequently by imidazoles. There was a clear benefit on life duration, but the results for aesthetic aspect are not satisfactory. In the discussion, we review treatment efficacy and failure; in fact, surgery which includes removal of infected tissue and reconstructive procedures, is seldom curative. Several combinations of drugs have been used with different degrees of success. Nevertheless imidazoles remain more efficient than amphotericin B.

Rhino-orbitocerebral entomophthoramycosis

Conidiobolus coronatus is recognized as a human pathogen causing subcutaneous fungal infection of the face in immunocompetent patients. The disease process is usually benign. We report, what we believe to be the first case of intracranial extension of C. coronatus producing rhino-orbitocerebral syndrome, and subsequent dissemination of C. coronatus in an immunocompetent patient.

Seasonal variations in rhino-cerebral Mucor infection

OBJECTIVES

Rhino-orbito-cerebral mucormycosis (ROCM) is an uncommon, potentially lethal infection that occurs mostly in immunocompromised hosts. The seasonal occurrence of ROCM was studied in two of Israel's largest medical centers.

METHODS

A total of 36 patients were seen during a 25-year period in this retrospective bi-institutional cohort study. Meteorologic data were obtained and analyzed for a possible linkage of infection with precipitation and temperature.

RESULTS

Twenty-one of the 36 patients (58%) presented between the months of August and October, and 27 patients (75%) presented between the months of August and December. A peak incidence of ROCM was noted in the month of September (13/36 patients; 36%). No association was noted between meteorologic conditions and the incidence of ROCM infection.

CONCLUSIONS

A consistent seasonal peak was observed in ROCM. Heightened awareness is important for early recognition and treatment of this disease.

Early identification of rhinocerebral mucormycosis

OBJECTIVES

Mucormycosis is an acute and often fatal infection caused by a fungus of the Mucorales order of the Zygomycetes class. In the majority of cases, it is associated with an underlying disorder, such as diabetes mellitus with ketoacidosis, or with immunocompromising factors, but it may appear in healthy people, although rarely. Early diagnosis and treatment are critical to prevent an otherwise fatal outcome. This article presents and discusses the early (alarming) signs and symptoms and the predisposing factors that should be considered to avoid delays in diagnosis.

METHODS

We review seven cases of rhinocerebral mucormycosis admitted to our hospitals from 1998 to 2003.

RESULTS

All patients had an underlying immunocompromising factor and/or diabetes mellitus. Five patients had palatal necrotic ulcers and/or black eschars. Three patients had unilateral blindness, and two patients required orbital exenteration. Four patients died because of a delayed diagnosis.

CONCLUSIONS

Early diagnosis is critical in the prevention of intracranial extension of the infection, which is the cause of death in 80% of cases. Therefore, a high index of clinical suspicion is essential in immunocompromised or diabetic patients with acute sinus infection. Identification of a fungal organism on histopathology is the most specific element for diagnosis. A team approach to management is recommended for early surgical debridement, correction of diabetic ketoacidosis, and systemic antifungal agents. Timely medical-surgical treatment proves extremely important for prognosis.