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LETTER
Year : 2015  |  Volume : 61  |  Issue : 2  |  Page : 143-144

Nasal conidiobolomycosis: A successful treatment option for localized disease


1 Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India
4 Department of Medicine and Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication13-Mar-2015

Correspondence Address:
L M Cherian
Department of Otorhinolaryngology, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.153112

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How to cite this article:
Cherian L M, Varghese L, Panchatcharam B S, Parmar H V, Varghese G M. Nasal conidiobolomycosis: A successful treatment option for localized disease. J Postgrad Med 2015;61:143-4

How to cite this URL:
Cherian L M, Varghese L, Panchatcharam B S, Parmar H V, Varghese G M. Nasal conidiobolomycosis: A successful treatment option for localized disease. J Postgrad Med [serial online] 2015 [cited 2019 Nov 14];61:143-4. Available from: http://www.jpgmonline.com/text.asp?2015/61/2/143/153112


Sir,

A 42-year-old male agricultural worker presented with painless, progressive left nasal swelling and obstruction of 3 months duration. There was no other significant history other than frequent nose picking. An examination revealed irregular, nodular lesion involving the anterior part of cartilaginous septum, vestibule, floor of nose and inferior turbinate. Initial fungal smear and biopsy showed aseptate fungal hyphae. Computerized tomography correlated with clinical findings. The patient underwent resection of the entire lesion. The tissue on calcofluor white preparation showed broad aseptate fungal hyphae. The sample was inoculated on Sabouraud's dextrose agar plates with and without antimicrobials and brain heart infusion agar, and incubated at 25° C. The plate after 48 hours on obverse and reverse showed cream, waxy growth with satellite colonies. Lactophenol cotton blue preparation from the colonies showed broad hyphae, short erect conidiophores and large round conidia giving rise to secondary conidia. The colony morphology was consistent with Conidiobolus coronatus. Histopathology showed tissue eosinophilia and Splendore-Hoeppli phenomenon surrounding broad aseptate hyphae with no evidence of angioinvasion [Figure 1] and [Figure 2]. The case was diagnosed as conidiobolomycosis and the patient started on oral itraconazole 200 mg twice a day and terbinafine 250 mg three times a day for 6 months. On follow up at 6 months there were no signs of local residual lesion or recurrence [Figure 3].
Figure 1: (H&E stain, 20 × magnifications) Respiratory mucosa with dense stromal infiltrates of lymphocytes, eosinophils, a few plasma cells and a few ill-formed granuloma composed of epithelioid histiocytes and a few Langhans-type multinucleated giant cells

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Figure 2: Image a (PAS stain, 40×), image b (GMS stain, 40×) highlighting smudgy eosinophilic material, representing Splendore Hoeppli phenomena, with adjacent eosinophils, Langhans-type multinucleated giant cells and a few aseptate thick-walled hyphae and spore forms

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Figure 3: Postoperative picture with no residual or recurrent disease

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Conidiobolomycosis caused by the fungus conidiobolus which belongs to the order entomophthorales of the class zygomycetes is a rare invasive subcutaneous mycosis of the rhinofacial region affecting immunocompetent individuals. The fungus is present in soil and decaying vegetations. [1] Conidiobolomycosis occurs mainly in tropical regions of Africa, South and Central America and South East Asia. The infection is usually among adults engaged in farming and other outdoor activities and is acquired by inhalation or inoculation. This probably explains the male predominance of the infection. [2] C. coronatus is the most common agent causing conidiobolomycosis. C. incongruous and C. lamprauges have also been reported to cause human disease. [3]

The clinical presentations often mimic malignancy or granulomatous diseases with subcutaneous nodular lesion and mucosal inflammation resulting in nasal obstruction, discharge, epistaxis and deformity. [4] The infection can spread to paranasal sinuses, facial soft tissue, intracranium, mediastinum or lungs. Hence, an early and accurate diagnosis is essential. Treatment of conidiobolomycosis includes surgical debridement followed by antifungal therapy. The optimal antifungal therapy is unknown. Anecdotal reports describe treatment using monotherapy or combination therapy with amphotericin B, oral itraconazole, fluconazole, voriconazole, potassium iodide, terbinafine and co-trimoxazole. [5] The dosage and duration of the drugs again is not well defined. In our patient, the response was excellent. There were no renal, hepatic function abnormalities or any other side effects during therapy or follow up. Treating physicians could consider debridement followed by combination therapy with itraconazole and terbinafine as a good therapeutic option in localized conidiobolomycosis.

 
 :: References Top

1.
Pfaller MA, Diekema DJ. Unusual fungal and pseudofungal infections of humans. J Clin Microbiol 2005;43:1495-504.  Back to cited text no. 1
    
2.
Martinson FD, Clark BM. Rhinophycomycosis entomorphthorae in Nigeria. Am J Trop Med Hyg 1967;16:40-7.  Back to cited text no. 2
    
3.
Kimura M, Yaguchi T, Sutton DA, Fothergill AW, Thompsom EH, Wickes BL. Disseminated human conidiobolomycosis due to Conidiobolus lamprauges. J Clin Microbiol 2011;49:752-56.  Back to cited text no. 3
    
4.
Bento DP, Tavares R, Martins Mda L, Faria N, Maduro AP, Araújo C, et al. Atypical presentation of entomorphthoromycosis caused by Conidiobolus coronatus. Med Mycol 2010;48:1099-104.  Back to cited text no. 4
    
5.
Fischer N, Ruef Ch, Ebnöther C, Bächli EB. Rhinofacial Conidiobolus coronatus infection presenting with nasal enlargement. Infection 2008;36:594-6.  Back to cited text no. 5
    


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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
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