Rhinoschleroma

A 39 year-old man came to our institution because of a five-year history of a progressive painful growing mass on his left nostril, which cause airway obstruction with ulceration. Because of a suspicion of malignancy, surgery (mass resection and subtotal nasal reconstruction) was performed. Histologic samples ruled out malignancy, and tissue cultures for fungus and mycobacteria were negative, but regular aerobic cultures were positive for Klebsiella rhinoscleromatis. The patient was given a six-month regimen of ciprofloxacin, and a dramatic improvement was observed.

Rhinoscleroma: an updated experience through the last 10 years

CONCLUSION

Rhinoscleroma is a chronic, specific, granuloma of the nose and other parts of the respiratory system. The disease is endemic in Egypt and many other countries. The causative organism is Klebsiella rhinoscleromatis bacillus, proved by fulfilling Koch's postulates. The mode of infection is not known and its worldwide irregular geographical distribution is not understood. Lines of treatment are unsatisfactory and a tendency for recurrence is the rule.

OBJECTIVES

Our aim was to study the clinical presentation, microbiology, pathological staging, follow-up, and lines of treatment of new rhinoscleroma patients admitted or seen at Alexandria Main University Hospital from January 1999 until January 2009.

METHODS

Demographic data and the results of clinical, bacteriological, and histological examinations were reviewed. Medical and surgical treatments were evaluated. Follow-up as regards the results of treatment and incidence of recurrence was assessed.

RESULTS

Fifty-six patients were included in the study. There were 26 males and 30 females, and 85% of patients presented in the third and fourth decades of life. The nose was affected in 100% of patients. Other regions affected were the nasopharynx in 13 patients, palate in 7 patients, skin in 2 patients, larynx in 3 patients, trachea in 17 patients, nasolacrimal duct in 2 patients, and premaxilla in 1 patient. No lymph node affection was reported. Klebsiella rhinoscleromatis strain III was isolated from 100% of patients. Antibiotics used were a combination of trimethoprim-sulfamethoxazole 400 mg and rifampicin 300 mg twice daily for 3 months. Since 2003, this was replaced by ciprofloxacin 500 mg twice daily for 3 months. Surgical procedures performed were removal of nasal granulations, bronchoscopic dilatation, bipolar coagulation of skin lesions, tracheostomy, and repair of pharyngeal stenosis. Results were disappointing, as a large number of patients did not attend for follow-up. A high incidence of recurrence was found, reaching up to 25% within 10 years.

Rhinoscleroma: a case report

Rhinoscleroma is a chronic inflammatory disease in which granulation tissue with a typical cell content is found. The paper presents the case of a 77-year-old woman with clinically diagnosed nodule in the nasal cavity. The histopathological examination revealed granulation tissue with plasma cells and Mikulicz's cells. The clinical and morphological picture of the case in question is a rare opportunity to bring to mind a disease that used to be common in Poland and which clinically can imitate malignant tumour.

[Application of enzyme linked immunosorbent assay (ELISA) for diagnosis of antibodies to lipopolysaccharide of Klebsiella rhinoscleromatis in patients with rhinoscleroma]

The ELISA were performed on polystyrene microtiter plates (Nunc, MaxiSorp) coated with LPS (2a antigen) at the final concentration of 10 microg/ml. The antigen was extracted from Klebsiella rhinoscleromatis Rh32 by the trichloroacetic acid and separated by ethanol (Boivin method). The antibodies against the LPS were detected by ELISA in serum samples collected from 65 patients suspected in clinical investigation for rhinoscleroma in Poland from 1970 to 2009. Additionally, the specificity of the antigen was tested using serum sample of immunized rabbit and 30 sera of patients from control group, with high level of antibodies to different bacterial pathogens. All serum samples were diluted 1:100. The concentrations of IgA, IgG and IgM antibodies were expressed as optical density (OD) measured at the wavelength of 450 nm. The cut-off limit of serum antibodies was set at mean antibody OD determined in the sera of 30 blood donors exceeded by three standard deviations. The presence of IgA and IgG antibodies were detected by ELISA in 33 (50,8%) and IgM in 28 (43,1%) of patients. Most of the serum samples (75%) with high level of specific antibodies were obtained from patients before 1980. On the other hand antibodies to K. rhinoscleromatis were detected only in 2 (6,7%) patients from the control group and none of blood donors. In conclusion, our home-made ELISA, based on purified LPS of K. rhinoscleromatis showed high specificity and sensitivity in the diagnosis of antibodies to K. rhinoscleromatis in comparison to the complement fixation test. The presence of high level of specific IgA, IgG and IgM antibodies in the sera obtained in different stages of disease may showed that during the rhinoscleroma is permanent stimulation of antibody production.

[Pathologic diagnosis of specific infections in upper aerodigestive tract]

OBJECTIVE

To find a fast and simple method for detection of specific pathogens in upper aerodigestive tract.

METHODS

Sixty-one cases of specific infections in upper aerodigestive tract encountered during a 10-year period in Beijing Tongren Hospital were retrospectively studied. Six histochemical stains, including PAS, Giemsa, Gram, methylene blue, modified Warthin-Starry and acid-fast stains were applied. The morphology of different pathogens was studied and the staining patterns were compared.

RESULTS

There were 23 cases of pharyngeal treponemal infection, 10 cases of short treponemal infection, 4 cases of mycobacterial infection, 4 cases of infection by rhinoscleroma bacilli, 1 case of sinonasal fungal infection, 1 case of combined infection of bacteria and Oidium albicans, 2 cases of tonsillar Actinomycetes and 16 cases of non-specific bacterial infections. Both pharyngeal treponemal infection and infection by rhinoscleroma bacilli could be detected by modified Warthin-Starry stain. As for sinonasal fungal infection, PAS, Giemsa and modified Warthin-Starry stains were useful in differentiating different types of fungi. Mycobacteria were best demonstrated by conventional acid-fast stain.

CONCLUSIONS

Special histochemical stains performed on histologic sections are useful for diagnosing specific infections in upper aerodigestive tract.

Klebsiella rhinoscleromatis of the membranous nasal septum

Rhinoscleroma is a chronic, infectious, granulomatous disease that may present with mass lesions in the respiratory tract anywhere from the nose to the trachea. The nose is involved in 95-100 per cent of cases. There are three stages of the disease: catarrhal-atrophic, granulomatous (also known as hypertrophic) and sclerotic. The diagnosis is made either by positive Klebsiella rhinoscleromatis culture or from the classic histological findings of Mikulicz cells and transformed plasma cells with Russell bodies. Rhinoscleroma is endemic to areas of Africa, South-East Asia, Mexico, Central and South America, and Central and Eastern Europe, and it has been associated with low socioeconomic status. In the past, rhinoscleroma was infrequent in the US population but, with current trends in migration, the incidence of rhinoscleroma may be on the rise. There is often a delay in diagnosis in non-endemic areas such as the US due to unfamiliarity with the disease, the stage-dependent clinical and histological manifestations of disease, and the fact that only 50-60 per cent of cultures are positive for K rhinoscleromatis. Such late diagnosis leads to increased morbidity in the form of nasal and airway obstruction and nasal deformity from erosive processes. Rhinoscleroma is difficult to cure and prone to recur. Currently, the recommended treatment consists of a combination of surgical debridement and long-term antibiotic therapy. We present a case report of a culture-positive diagnosis of rhinoscleroma, and we review the existing literature.

Chronic nasal infection caused by Klebsiella rhinoscleromatis or Klebsiella ozaenae: two forgotten infectious diseases

OBJECTIVES

Klebsiella rhinoscleromatis and Klebsiella ozaenae are associated with chronic diseases of the upper airways: rhinoscleroma and ozena, respectively. These have become uncommon in developed countries. We report herein one case of each disease in patients living in Marseilles, France, and include a review of the literature.

METHODS

Diagnosis was made by direct evidence of bacteria (specific cultures and autoimmunohistochemistry on nasal biopsy) and using an indirect method (serology). In addition, the literature review showed that the majority of publications were old, confirming the fact that these diseases have been long forgotten.

RESULTS

The specific and original methods used have allowed us to confirm the pathogenic role of K. ozaenae in ozena and confirmed rhinoscleroma in a granulomatous lesion. In the literature, K. rhinoscleromatis is only associated with rhinoscleroma whereas K. ozaenae is also associated with clinical diseases other than chronic rhinitis.

CONCLUSIONS

In cases of chronic rhinitis, ozena and rhinoscleroma should be kept in mind, even in developed countries, and systematically screened for, especially as there are specific diagnostic tools and effective treatments available.

Rhinoscleroma: a clinicopathological study from the Gulf region

INTRODUCTION

Rhinoscleroma is a chronic progressive inflammatory disease of the upper respiratory tract. We report a clinicopathological series from the Gulf region.

METHODS

The clinical and pathological features of patients diagnosed with rhinoscleroma at three main hospitals in Saudi Arabia and Bahrain over a 20-year period are presented. Archived glass slides and paraffin blocks from these patients were retrieved from the pathology files for review. Special stains were performed whenever indicated. Biopsy material and clinical data from 25 patients formed the basis of this study.

RESULTS

Most of the patients were young females with a median age of 24 years. The nose was involved in all cases with frequent extension to other parts of the upper respiratory tract. The provisional clinical diagnoses included syphilis, midline granuloma and malignancy. The histological differential diagnoses included leprosy, malakoplakia and metastatic renal cell carcinoma.

CONCLUSION

Rhinoscleroma is rare in Saudi Arabia and Bahrain. Awareness of possible clinical presentations and early diagnosis will significantly reduce the morbidity caused by this disease.

Modification of lymphocyte subsets in patients with rhinoscleroma

PURPOSE

Rhinoscleroma is a rare, chronic, granulomatous disorder of the upper airways. This disease presents some etiopathogenetic aspects that are not yet clear. Infection by Klebsiella rhinoscleromatis is fundamental for the onset of the disease, but it is impossible to reproduce rhinoscleroma experimentally only via infection with the bacteria both in man and in animals. Furthermore, this disease mainly affects blood-related people and occurs in certain geographic areas. In this context, we present a study that brings to light some of the quantitative abnormalities of the lymphocyte subsets.

MATERIALS AND METHODS

The study group consisted of 5 patients with rhinoscleroma. The following parameters were studied for each patient: clinical manifestations, histologic examinations, number of leukocytes, lymphocytes, and lymphocyte subsets.

RESULTS

In all patients, we noted the following: There was a relative reduction of the CD4+ cells, an absolute increase of the CD8+ cells, and an inversion of the CD4+/CD8+ ratio. There was an absolute increase of the CD56+ cells and cytotoxic cells that coexpress CD8+CD56+ antigens. There was a relative reduction of the CD3+ cells, and the CD19+ cells tended to show an ambiguous behavioral pattern.

CONCLUSION

We believe that K. rhinoscleromatis does not play a major role in the etiopathogenesis of rhinoscleroma. However, we do believe that the anomalous behavior of the immune system can favor rhinoscleroma.

Laryngeal scleroma associated with Klebsiella pneumoniae subsp. ozaenae

Klebsiella pneumoniae subsp. ozaenae was isolated from the pharynx of a woman with laryngeal scleroma. K. pneumoniae subsp. ozaenae is rarely isolated from clinical infections and has never been reported in laryngeal scleroma, which is usually caused by K. pneumoniae subsp. rhinoscleromatis.

Rhinoscleroma in three siblings

Rhinoscleroma is a chronic, granulomatous infectious disease that responds poorly to treatment. In recent years an increasing number of cases have been reported in nonendemic areas, explained largely by major migratory movements. We describe rhinoscleroma in three siblings. They had ulcerated but painless lesions, which bled spontaneously, and hemorrhagic scabs or crusts in their noses. In one child, the lesions had destroyed the entire left nasal ala and alar cartilage and most of the right. Dermatopathologic study identified the Mikulicz macrophages that contained organisms. It is possible that disposing factors could have been the neutropenia common to the three children and their poor living conditions. They were treated with a combination of trimethoprim-sulfamethoxazole and cefalexin, for a period of 3 months. We present this unusual case history of three siblings affected by a process that is relatively infrequent in our area of practice and is not considered very contagious. It is important to recognize the clinical signs characteristic of this disease, the diagnosis of which is not easy. Improvements in living conditions, hygiene, and health standards are essential prerequisites for its control and prevention.

[Clinicopathologic analysis of rhinoscleroma]

OBJECTIVE

To investigate the clinicopathologic characteristics and reason of tissue injury caused by klebsiella rhinoscleromatis(KR) infection.

METHODS

Twenty-four cases of rhinoscleromas in the nasal and pharyngeal region in this hospital from March 1983 to March 1998 were studied retrospectively. Warthin-Starry (W-S) stain was used in all cases and CD43, CD20, CD68, Lysozyme mark were observed in eleven specimens by ABC immunochemical method. Two cases were studied further with transmission electron microscopy.

RESULTS

A great number of KR were found in Mikulicz cells and were confirmed further in the phagosomes in cytoplasm of Mikulicz cells, where a small number of endoplasmic reticulums and lysozymes was squeezed to the side of cells. A few of T-lymphocytes was found within the granuloma.

CONCLUSION

Cellular immunity function of the patient with rhinoscleroma was depressed and the response to immunization of host which regards to KR was the major cause of tissue injury.

[An etiological and pathologic study of Rhinoscleroma]

OBJECTIVE

To investigate the clinicopathologic characteristics and mechanism of tissue injury caused by Klebsiella rhinoscleromatis (KR) infection.

METHODS

Thirty-three cases of rhinoscleromas in the nasal and pharyngeal region seen in this hospital from Jan. 1980 to Mar. 2000 were studied retrospectively. Warthin-Starry (W-S) stain was used to study all cases. Five cases were studied further with transmission electron microscope.

RESULTS

W-S stain revealed a great number of KR in Mikulicz cells within the granuloma. Electron microscopy demonstrated a number of phagosomes in the cytoplasm of Mikulicz cells where many KR were found. A small number of other organelles such as endoplasmic reticulums and lysozymes were squeezed to the side of cells. There were many granular substances on the surface of intracellular bacteria, which were not found on the extracellular KR.

CONCLUSION

KR is a facultative intracellular bacteria that is able to resist the digestion of macrophages and to proliferate in them. Formation of granulomas and fibrosis in KR infiltrated regions is the major cause of tissue injury.

Experimental intravenous inoculation of Klebsiella rhinoscleromatis bacilli in albino rats: a histopathological and bacteriological study

Scleroma, chronic specific granuloma of the nose and upper respiratory tract, is endemic in Egypt and many other countries. The exact pathogenesis of the disease as regards the aetiological role of Klebsiella rhinoscleromatis is contradictory. This work investigated the effect of experimental intravenous injection of K. rhinoscleromatis in albino rats to demonstrate that the micro-organism can fulfil Koch's postulates. Micro-organisms were isolated from biopsy specimens taken from nasal lesions of 10 patients in the granulomatous stage of scleroma. Specimens were subjected to bacteriological and histopathological examinations to confirm the diagnosis. A 100 microl volume of freshly prepared bacterial inoculum containing 10(8) cfu/ml was injected weekly in the tail vein of each of 30 albino rats for 5 consecutive weeks. Biopsy specimens were taken from sacrificed animals and subjected to bacteriological and histopathological examinations. Positive histopathological diagnosis of scleroma was reported in the nose of 66.7% of rats, the larynx of 46.7%, the lungs of 26.7% and liver of 20% of rats. Bacteriological techniques were successful in revealing K. rhinoscleromatis from the nose of 36.7% of rats, the larynx of 30% and the lungs of 20% of rats. Various techniques were carried out to demonstrate the micro-organisms in tissue sections. Two histochemical stains for bacteria were employed: silver and Periodic Acid Schiff (PAS) stains. Immunoperoxidase technique using Klebsiella capsular type 3 antiserum was applied. It gave positive results in 66.7% of the 6 stained liver sections in spite of negative bacteriological cultures. The histiocytic nature of the Mikulicz cells was confirmed using alpha-1 antitrypsin, an immunohistochemical marker of histiocytes, and by studying the ultrastructural features of Mikulicz cells using the transmission electron microscope.

[Rhinoscleroma. A case report]

Rhinoscleroma is a chronic, specific, inflammatory granulomatous condition of the nose and other structures of the upper respiratory tract. It is caused by the bacterium Klebsiella rhinoscleromatis. We report a case in a 29-year-old black male emigrant who consulted for a 2-year history of hoarseness, cough, and nasal discharge. The diagnosis was scleroma with nasal, laryngeal, tracheal, and bronchial involvement and ulcerating and necrotizing lesions that caused respiratory obstruction. Bacterial over-infection responded to treatment with third-generation cephalosporins and clindamycin. The sclerotic lesions responded well to treatment with ciprofloxacin. We review the clinical findings at different stages, diagnostic options, and several treatments.

[Spheno-ethmoidal rhinoscleroma. Report of a case and review of the literature]

We report an unusual case of spheno-ethmoidal rhinoscleroma. This chronic granulomatous disease occurs sporadically in Western Europe. Culture is necessary for diagnosis showing the causative organism of rhinoscleroma, Klebsiella rhinoscleromatis. Immunocytochemistry is used in any suspicious case with a negative culture. Antibiotics are the mainstay of therapy for several weeks, using ciprofloxacine or rifampicin, until the nasal biopsies demonstrated no Klebsiella organism.

Respiratory scleroma: a clinicopathologic and ultrastructural study

Respiratory scleroma (rhinoscleroma) is a chronic granulomatous infection produced by Klebsiella rhinoscleromatis, a gram-negative aerobic coccobacillus. This disease is endemic to Africa, Central and South America, South Central and Eastern Europe, the Middle East, and China. Sporadic cases have been reported in the United States, especially in persons who migrated from the aforementioned areas. The majority of cases affect the nose, but extension to the soft and hard palate, upper lip, and maxillary sinuses also is frequent. This study comprises 11 patients (6 females and 5 males) with respiratory scleroma identified over a 6-year period in Guatemala. Their ages ranged from 16 to 60 years. Light microscopy showed a dense plasmacytic infiltrate, Mikulicz histiocytes, and Russell bodies within the plasma cells. Ultrastructural study revealed Mikulicz histiocytes, cytoplasmic vacuoles containing bacilli, and so-called A and B granules. We favor the term respiratory scleroma for this lesion because it affects not only the nose but also the upper and lower respiratory tracts as well as the mouth.

Laryngotracheal manifestations of rhinoscleroma

Rhinoscleroma is a rare, chronic granulomatous disease of infective causation. It usually begins in the nose and may progress to involve the larynx and trachea and cause dysphonia, stridor, and airway obstruction. Early rhinoscleroma is usually successfully treated with oral tetracycline, yet laryngotracheal disease may require operative intervention. The disease is rare in the United States, but with an increase in immigration from endemic areas, otolaryngologists should be familiar with the management of this rare disease. Current literature contains only a few reports describing the manifestations of this disease, mostly in the form of case studies. This study is a retrospective review of our institutional experience with the management of 22 patients with rhinoscleroma, 13 of whom had laryngotracheal involvement. The focus of this report is on the clinical manifestations of laryngotracheal scleroma. All of the patients were treated with long-term antibiotics. Nine patients underwent endoscopy with or without dilation and laser excision. Three patients required emergency tracheostomy, all of whom were ultimately decannulated without any sequelae. A rational approach to management of this unusual disease is provided.

Isolated subglottic scleroma

Scleroma, more commonly known as rhinoscleroma, is a progressive, chronic, granulomatous disease of the respiratory tract and adjacent tissues. Early diagnosis and prolonged therapy are critical in avoiding its late sequelae. We describe an unusual case of scleroma presenting as worsening chronic lung disease. The variety of clinical presentations and treatment modalities is reviewed.

Cytomorphologic features of scleromatous lymphadenitis on fine-needle aspiration cytology: a case report

Scleroma is a chronic granulomatous inflammatory disease of the upper respiratory tract caused by Klebisella rhinoscleromatis. Scleromatous involvement of lymph node is rare. The smears on fine-needle aspiration reveal a characteristic picture. The cytomorphologic features of this rare lymph node lesion are reported.

[Acquired stenosis of the nasopharynx]

A case of scarring stenosis of the nasopharynx occurring in the fifth decade without previous medical history is presented. Transpalatal resection with a prolonged stent, produced patent nasal cavities, but the different studies performed did not establish the etiological diagnosis. A final stage of rhinoscleroma was suspected.

In vitro activities of streptomycin and 11 oral antimicrobial agents against clinical isolates of Klebsiella rhinoscleromatis

We tested in vitro the activities of streptomycin and tetracycline--antibiotics that have long been used to treat rhinoscleroma--as well as several newer oral agents by using 23 isolates of the causative organism Klebsiella rhinoscleromatis. All isolates were inhibited by clinically achievable concentrations of trimethoprim-sulfamethoxazole, amoxicillin-clavulanate, chloramphenicol, ciprofloxacin, cephalexin, cefuroxime, and cefpodoxime.

[Ultrastructural studies of Klebsiella rhinoscleromatis]

In 1870, F. Hebra described a slowly progressing granulomatous disease of the nasal mucous membrane he called rhinoscleroma. Later, N. M. Volkovich and A. Frisch isolated from patients suffering from this disease a microorganism they termed Klebsiella rhinoscleromatis. In 1932, S. Belinov proposed to name the disease Scleroma respiratorium because the pathological process developing in rhinosclerosis may involve not only upper but also lower airways. In 1961, T. Steffen and J. Smith demonstrated that Klebsiella rhinoscleromatis conformed to Koch's postulates and was an etiological factor of inflammatory changes typical of scleroma. This paper presents results of ultrastructural examinations of Klebsiella rhinoscleromatis isolated from two patients with Scleroma respiratorium. It was shown that as the degenerative process developed, the amount of electron-dense material around the bacterial cell wall decreased progressively and only fragments of the cellular membrane remained.

Rhinoscleroma

We have described a case of rhinopharyngeal rhinoscleroma, and reviewed the clinical behavior and management of this disease. Selective long-standing antibiotic treatment was successful in halting the process. Treatment of the advanced cicatrix with carbon-dioxide laser vaporization yielded excellent results.

Cytologic diagnosis of rhinoscleroma

The cytologic diagnosis of a case of rhinoscleroma was made on brushing specimens of a laryngeal lesion. The cytologic picture included aggregates of the characteristic Mikulicz cells, large, rounded histiocytes with an eccentric nucleus and vacuolar cytoplasm containing the short rods of Klebsiella rhinoscleromatis. Although the diagnosis of this chronic infectious disease involving the upper respiratory tract is routinely made by tissue biopsy and bacteriologic study of the lesions, the present report indicates that cytology has a definite place in its diagnosis.

Rhinoscleroma--a diagnostic challenge

Rhinoscleroma is a rare chronic granulomatous infection predominantly affecting the upper respiratory tract. The patient presented here exemplifies several features of the disease, including the fact that diagnosis may elude the clinician for years, and this delay may increase morbidity substantially. The most common initial complaint is nasal obstruction, and physical examination frequently reveals erythematous granular or nodular swellings covered with crusts. Its tumor-like appearance and local spread arouses suspicion of malignancy, but differential diagnosis also includes fungal infections and numerous granulomatous diseases. The classic histopathology consists of large vacuolated Mikuliz's cells and transformed plasma cells with Russell bodies. Numerous antibiotics have been used for treatment of this infection with varying degrees of success. Long-term follow-up is important because these patients can have numerous relapses. Geographic distribution is also discussed.

Identification of rhinoscleroma by immunoperoxidase technique

Rhinoscleroma is a chronic disease of the respiratory system. Its onset is insidious and its symptoms are often nonspecific. Yet rhinoscleroma is a progressive disease that can lead to significant disability. The proper diagnosis is difficult because of the nonspecific presentation and rarity of rhinoscleroma. Biopsy tissue often is not properly cultured. Diagnostic histologic features may not be readily apparent or may be overlooked by the unsuspecting pathologist. A case of rhinoscleroma is reported in which an immunoperoxidase technique was applied to retrospectively confirm the diagnosis. The usefulness of this new technique in the diagnosis of rhinoscleroma is discussed.

[A contribution to diagnosis, specificity and treatment of rhinoscleroma (author's transl)]

As a disease with a peculiar geographical distribution rhinoscleroma is a kind of chronic inflammation which may cause some diagnostic difficulties in non-endemic regions. In general, the diagnosis based on histological features and the microbiological identification of the causative agent. In case where a definite microbiological identification could not be achieved the diagnosis should be expressed in the following terms: "rhinosclerotic granuloma with features of specificity". The diagnosis is facilitated by the aid of cytological methods which are easy to perform and do not hurt the patient. The characteristic cells of the Mikulicz type may be observed in the smear. This paper presents the case of a 25-year old man with a rhinosclerotic granuloma of the larynx which caused dyspnea and aphonia. The diagnostic procedure was done by cytological, histological and ultrastructural methods. The patient was treated by surgery and by applications of antibiotics.

Transmission and scanning electron microscopic studies of rhinoscleroma

Using both types of electron microscope, combined transmission and scanning electron microscopic studies were done on 6 patients with rhinoscleroma. The present work suggests the possibility of two types of organisms causing the disease: one type--being in the majority--was a rod-shaped bacillus measuring about 3 micrometers; the other type was a short, stout bacillus with terminal spiral cilia. The ultrastructure of these bacilli has been described. The advantages and limitations of each type of electron microscopy in the investigation of rhinoscleroma have been discussed.

Klebsiella rhinoscleromatis: a clinical and pathogenic enigma

Rhinoscleroma is a chronic, slowly progressive, infectious disease of the respiratory tract that can produce disability and death, if untreated. Once considered an anomaly in the United States, the disease is now seen more frequently in this country, owing to increased travel from endemic areas. This report presents a comprehensive review of the several types of therapy that have been published in the literature. The results of a clinical experiment are also presented.

Experimental scleroma. A histopathological study

Klebsilla rhinoscleromatis suspension was experimentally inoculated into the nose and maxillary sinus of eight adult healthy rabbits. Two normal litter-mates served as controls. The animals were killed at varying intervals up to five months following the inoculation. Histopathological examination of the upper and lower respiratory tracts revealed a consistent pulmonary peribronchial and perivascular granulomatous reaction with a Mikulic cell-like appearance. The reaction was present in all the inoculated rabbits and increased in severity as the survival period was prolonged. The significance of these findings in the aetiopathogenesis of scleroma and to scleroma in humans is discussed.

[Antibiotic sensitivity of Proteus, Pseudomonas pyocyanea and staphyloccoci isolated from scleroma and ozena patients]

Antibiotic sensitivity of 292 strains of Proteus, 60 strains of Ps, aeruginosa, 309 strains of S. aureus and 88 strains of S. epidermidis isolated from the upper respiratory tract of patients with scleroma and ozena was studied. The cultures of Pr. mirabilis were sensitive to aminoglucosides (54.9-96.2 per cent) and Pr. morganii were sensitive to levomycetin (81.5 per cent) and neomycin (92.6 per cnet). Sensitivity of Pr. vulgaris and Pr. morganii was reliably higher (p less than 0.001) than that of Pr. mirabilis. The strains of Pr. morganii were less sensitive to monomycin (P less than 0.001) and streptomycin (p less than 0.01) as compared to the cultures of other Proteus species tested. The strains of Ps. aeruginosa were sensitive only to gentamicin (90 per cent) and neomycin (81.1 per cent). Most of the strains of S. aureus (85.4-100 per cent) were sensitive to oleadomycin, erythromycin, olemorphocycline, tetraolean, oxacillin, methicillin ceporin, lincomycin, ristomycin, kanamycin, monomycin and gentamicin. Benzylpenicillin (90.8 per cent of the sensitive strains), ampicillin (67.1 per cent), tetracycline (66.7 per cent), levomycetin (68.6 per cent) and streptomycin (38.1 per cent) were less effective. Antibacterial therapy in cases with scleroma and ozena should be directed not only against causative agents of the diseases but also against the microbes developing due to disbacteriosis. Combination of parenteral and local use of the antibiotics in the treatment of chronic clebsiellesis decreased the isolation rate of Proteus and Ps. aeruginosa in the patients.

Rhinoscleroma: a scanning electron-microscopic study

Nasal biopsies from 6 patients with rhinoscleroma were studied by scanning electron microscopy. Numerous bacilli of different sizes were found on the epithelial surface. Few bacilli with thin spiral terminal cilia were seen over the surface of large protruding non-epithelial cells. These cells appeared to be the Mikulicz cells migrating from the tunica propria to the epithelial surface through small ulcerations. In the tunica propria, Mikulicz cells containing numerous bacilli were observed. In 4 patients, round bodies and long tubular structures were found on the epithelial surface. These bodies were suggested to be fungi, yet their exact nature and their relation to Klebsiella rhinoscleromatitis bacilli need further investigation.

Scleroma of the nose and pharynx

Scleroma of the respiratory tract was first recognized just over a century ago. The disease is endemic in a number of North African, Central American and Latin American countries. However, it has been only rarely seen in the United States. The progression of scleroma takes place through three stages. The first stage of rhinitis has an early catarrhal phase which progresses to one of atrophic rhinitis. The second stage is seen as a proliferative granulomatous growth which obliterates the nasal fossae. The third cicatricial stage is usually accompanied by pronounced scarring and retraction of the tissues involved. Because of the increased ease of international travel by both sea and air, more cases can be expected to occur in the United States. This paper is presented to alert physicians to suspect scleroma in any case of granulomatous disease of the respiratory tract.

[Rhinoscleroma with sinuso-orbitary invasion]

The authors present the case of an 11-year-old child with a slowly progressive tumoral invasion resulting in bilateral nasal obstruction, massive facial deformation, and an exophthalmos of the left eye. There was no impairment of the child's general health. The histological investigation revealed the presence of Mikulicz' cells and von Frisch's bacilli. The resultant diagnosis was rhinoscleroma.

[Electron microscopical investigation of rhinoscleroma (author's transl)]

A boy from Togo with a resistent Rhinoscleroma was observed. The specific granuloma was examinated by histological and electron microscopic methods. The plasma cells form fibrillary material or guttate Russel bodies in the rough endoplasmatic reticulum. The morphology of Mikulicz-cells and Klebsiella rhinoscleromatis is described. The cells are supposed to be (histiocytic) macrophages. The surface of the germs is coated with a fimbria-like radiate substance which in the vacuoles of the cells is crosslinked. This material could be the eliciting antigen for the formation of Russel bodies. These bodies then may represent immune substances bound within the cell.

The management of rhinoscleroma

This investigation showed that the organism klebsiella rhinoscleromatis was present consistently in our cases. It was found to be difficult to eradicate completely although seemingly sensitive to common antibiotics in vitro. A prolonged treatment with bactericidal antibiotics is therefore necessary to eradicate it. Nasal dilatation rather than excision of granulations is required to restore nearly-normal physiological nasal function. Excision or cautery of granulations inside the nose is discouraged so as to avoid atropic changes.