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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~  References
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CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 2  |  Page : 196-198
 

A case report of an uncommon phaeoid fungal infection in nasal polyposis and review of literature


Department of Microbiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Submission13-Mar-2013
Date of Acceptance13-May-2013
Date of Web Publication19-Jul-2013

Correspondence Address:
S A Ganju
Department of Microbiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.115233

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 ~ Abstract 

Nasal polyposis is an inflammatory condition of mucous membrane of the nose and paranasal sinuses with unknown aetiology. Massive nasal polyps can obstruct the nasal cavity causing discomfort and lowered quality of life. Thus, aetiological diagnosis is important for treatment, especially in recurrent nasal polyposis. We present a rare case of pansinusitis with bilateral ethmoidal polyps caused by an unusual phaeoid fungus Fonsecaea pedrosoi in a 65-year-old immunocompetent male from a rural background. The diagnosis was made by endoscopic nasal examination; high resolution computed tomography of the paranasal sinuses, detection of fungal hyphae in 10% potassium hydroxide wet mount and culture.


Keywords: Culture, fungi, nasal polyposis


How to cite this article:
Ganju S A, Bhagra S, Kanga A K, Singh D V, Guleria R C. A case report of an uncommon phaeoid fungal infection in nasal polyposis and review of literature. Indian J Med Microbiol 2013;31:196-8

How to cite this URL:
Ganju S A, Bhagra S, Kanga A K, Singh D V, Guleria R C. A case report of an uncommon phaeoid fungal infection in nasal polyposis and review of literature. Indian J Med Microbiol [serial online] 2013 [cited 2019 Jun 18];31:196-8. Available from: http://www.ijmm.org/text.asp?2013/31/2/196/115233



 ~ Introduction Top


Nasal polyposis (NP) is a common tumour of the nasal cavity with a prevalence rate of 1-4%, being more common in adults than in children. [1] These are considered to be a subgroup of chronic rhinosinusitis and present as pedunculated smooth, gelatinous, semi-translucent, round or pear-shaped masses of inflamed mucosa prolapsing into the nasal cavity. [2] Although several possible causative agents have been implicated, it is difficult to single out the exact cause. The association between fungal organisms and rhinosinusitis was first described by Millar et al. [3] Recent studies have suggested that fungal rhinosinusitis could further lead to development of severe nasal polyposis. Some fungi that are associated with inflammatory airway disease are Alternaria, Cladosporium, Aspergillus, and Candida species. [4] We present a rare case of pansinusitis with bilateral ethmoidal polyps from which Fonsecaea pedrosoi was isolated.


 ~ Case Report Top


A 65-year-old male, agriculturist reported to the Department of Otolaryngology with complaints of progressive nasal obstruction for the past 2 years, frequent sneezing and sometimes bleeding through the nose. There was history of recurrent upper respiratory tract infections, ear ache and vertigo. The patient had undergone right nasal polypectomy 20 years back.

The patient was afebrile and vital parameters were maintained. Local examination showed bilateral polypoidal mass in the nasal cavity which could be probed all around freely. Complete haematological and serological investigations were within normal limits. Plain and high resolution computed tomography scan of nose and parananasal sinuses revealed pansinusitis with bilateral ethmoidal polyps without any bony erosion or invasion. There was bilateral high frequency sensorineural hearing loss. The visual acuity for both eyes was 6/18. Functional endoscopic sinus surgery with ethmoidectomy and frontal sinusoidectomy (FESS) was done. The haematoxylin and eosin stained sections revealed tissue fragment lined by pseudostratified ciliated columnar epithelium. There was presence of loose oedematous stroma, with dilated congested vascular channels and benign seromucinous glands along with moderate infiltration of lymphocytes, plasma cells and eosinophils. The histopathologic findings were suggestive of a benign inflammatory polyp.

On microscopic examination with 10% potassium hydroxide (KOH), brown coloured septate hyphae were detected. Biopsy material was inoculated on a set of Sabouraud dextrose agar (SDA) with and without antibiotics and one tube of each set was incubated at 25°C and 37°C, respectively. On SDA, dark green to brown black colonies were seen after 2 weeks of incubation at 25 o C [Figure 1]. On further incubation, the colonies became folded and both obverse and reverse became black in colour. Lactophenol cotton blue examination of the teased fungal growth and slide culture demonstrated both Phialophora and Cladosporium type of sporulation. Typical 'flower in vase' appearance characteristic of Phialophora-like sporulation showing flask-shaped phialides with conidia extruding through the neck were seen [Figure 2]. [Figure 3] shows brown coloured elliptical conidia approximately 2 × 6 μm with projections at the ends representing the disjunctors as seen in Cladosporium-like sporulation. These features were consistent with Fonsecaea pedrosoi. The patient was managed surgically with FESS. He responded well to corticosteroid (fluticazone furoate), antihistaminic (azelistine) nasal spray and oral itraconazole.
Figure 1: Culture on SDA showing black coloured colonies both on (a) obverse and (b) reverse

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Figure 2: LCB mount showing Phialophora-type of sporulation (flower in vase appearance) ×400

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Figure 3: LCB mount showing brown coloured septate hyphae along with Cladosporium-type of sporulation (elliptical conidia with disjunctors) ×400

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 ~ Discussion Top


Although NP is a common nasal tumor leading to a lowered quality of life, the exact aetiopathogenesis of NP remain unclear. These include viral and bacterial pathogens, aspirin intolerance, alteration in aerodynamics due to trapping of pollutants, inhalants, food allergens and epithelial disruption, epithelial cell defects or gene deletions. [5] The universal nature of fungal spores makes the role of fungal infection as cause or effect in nasal polyps difficult to determine but recent studies have reported fungal involvement in the development of nasal polyps. [6] Acute fungal rhinosinusitis should be suspected in individuals with intractable chronic rhinosinusitis (CRS), allergy and recurrent NP. [4] In our patient, polypectomy was done 20 years back and now he presented with recurrence of bilateral nasal polyps. Studies that have detected various fungi in the nasal polyposis are shown in [Table 1]. [1],[2],[4],[6],[7],[8] Recent studies have detected several unusual species like Ulocladium botrytis[9] and Schizophyllum commune[10] in NP and many more may be added to the list.
Table 1: Studies reporting fungi identified in nasal polyposis

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Isolation of fungi in NP is also largely dependent on the techniques used. Several authors have used "Ponikau's method" to isolate fungi; however, the culture rates vary from 49% to 96%. [11] In a university hospital using standard laboratory methods the fungal existence in CRS patients was reported to be 55.6%. [12] Important factors like risk of contamination and addition of mucolytic agents during sample collection and processing could be the reason for variable rates of fungal detection. In our study, 21 samples of NP were received from April 2012 to September 2012 and using standard microbiological techniques: Direct KOH wet mount, culture and microscopy; fungi were detected only in two cases. Fonsecaea pedrosoi was detected in one case and Penicillium species was isolated in the other. With close liaison and careful culture techniques in microbiology laboratory, positive results in cultures or microscopy up to 26.6% in CRS patients who underwent surgery have been reported. [13] Polymerase chain reaction technology has shown higher detection rates. [14] However, careful routine microbiological laboratory techniques remain the main stay in isolation of fungi in our settings.


 ~ Conclusion Top


Though PCR is a sensitive method but in resource limited settings microscopy and culture techniques are standard diagnostic tools to detect fungal infection. Clinical suspicion especially in case of recurrence of nasal polyps point towards a fungal aetiology, however, more studies are required to elucidate the relationship between fungi and nasal polyps.

 
 ~ References Top

1.Kordbacheh P, Zaini F, Sabokbar A, Borghei H, Safara M. Fungi as causative agent of nasal polyps. Iran J Public Health 2006;35:53-7.  Back to cited text no. 1
    
2.Razmpa E, Khajavi M, Hadipour-Jahromi M, Kordbacheh P. The prevalence of fungal infections in nasal polyposis. Acta Medica Iranica 2007;45:46-50.  Back to cited text no. 2
    
3.Millar JW, Johnston A, Lamb D. Allergic aspergillosis of maxillary sinuses. Thorax 1981;36:710.  Back to cited text no. 3
    
4.Shin SH, Ye MK, Lee YH. Fungus culture of nasal secretion of chronic rhinosinusitis patients: Seasonal variations in Daegu, Korea. Am J Rhinol 2007;21:556-9.  Back to cited text no. 4
[PUBMED]    
5.Bachert C, Wagenmann M, Rudack C, Hopken K, Hillebrandt M, Wang D, et al. The role of cytokines in infectious sinusitis and nasal polyposis. Allergy 1998;53:2-13.  Back to cited text no. 5
    
6.Aydil U, Kalkanci A, Ceylan A, Berk E, Kustimur S, Uslu S. Investigation of fungi in massive nasal polyps: Microscopy, culture, polymerase-chain reaction, and serology. Am J Rhinol 2007;21:417-22.  Back to cited text no. 6
    
7.Bassiouney A, Ragab A, Attia AF, Atef A, Hafez N, Ayad E, et al. Prevalence of extramucosal fungal elements in sinonasal polyposis: A mycological and pathological study in an Egyptian population. Am J Otolaryngol 2011;32:308-17.  Back to cited text no. 7
    
8.Dosa E, Doczi I, Mojzes L, Molnar EG, Varga J, Nagy E. Identification and incidence of fungal strains in chronic rhinosinusitis patients. Acta Microbiol Immunol Hung 2002;49:337-46.  Back to cited text no. 8
    
9.Kaur R, Wadhwa A, Gulati A, Agrawal A. An unusual phaeoid fungi: Ulocladium, as a cause of chronic allergic fungal sinusitis. Iran J Microbiol 2010;2:95-7.  Back to cited text no. 9
[PUBMED]    
10.Periæ A, Vojvodiæ D, Zolotarevski L, Periæ A. Nasal polyposis and fungal schizophyllum commune infection: A case report. Acta Medica (Hradec Králové) 2011;54:83-6.  Back to cited text no. 10
    
11.Ponikau JU, Sherris DA, Kern EB, Homburger HA, Frigas E, Gaffey TA, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999;74:877-84.  Back to cited text no. 11
    
12.Lebowitz RA, Waltzman MN, Jacobs JB, Pearlman A, Tierno PM. Isolation of fungi by standard laboratory methods in patients with chronic rhinosinusitis. Laryngoscope 2002;112:2189-91.  Back to cited text no. 12
    
13.Collins MM, Nair SB, Wormald PJ. Prevalence of noninvasive fungal sinusitis in South Australia. Am J Rhinol 2003;17:127-32.  Back to cited text no. 13
    
14.Catten MD, Murr AH, Goldstein JA, Mhatre AN, Lalwani AK. Detection of fungi in nasal mucsa using polymerase chain reaction. Laryngoscope 2001;111:399-403.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
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