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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 23  |  Issue : 3  |  Page : 123-125

Isolated soft-tissue aspergilloma at the right lateral side of nose mimicking as tuberculoma


1 Department of Ear, Nose and Throat, Yashoda Hospital, Hyderabad, Telangana, India
2 Laboratory Medicine, Yashoda Hospital, Hyderabad, Telangana, India
3 Radiology, Yashoda Hospital, Hyderabad, Telangana, India

Date of Submission13-Oct-2020
Date of Decision29-Mar-2021
Date of Acceptance05-May-2021
Date of Web Publication05-Oct-2021

Correspondence Address:
Dr. Majed Abdul Basit Momin
Malakpet, Nalgonda X-Roads, Hyderabad - 500 036, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_49_20

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  Abstract 


Aspergilloma is a mycotic infection and is characterized by a mass with soft-tissue attenuation without tissue invasion. Aspergilloma at the lateral aspect of the nose is a very rare location and poses clinical and diagnostic challenge as cytological examination mimics tuberculoma. We report the case of an immunocompetent elderly male with painless nodular swelling at the right side of the nose for 3 months with fine-needle aspiration cytology (FNAC) reported elsewhere as granulomatous inflammation suggestive of tuberculosis. Subsequently, repeat FNAC cytological examination with the application of special stain and submission of aspirated material for microbiological 10% potassium hydroxide mounting and culture-confirmed fungal infection as Aspergillus flavus. A high index of clinical suspicion, the utility of FNAC, application of special stains, and communication with pathologist and microbiologist clinches the diagnosis. The patient was successfully treated with antifungal therapy (Voriconazole) and swelling completely resolved after 6 weeks of treatment.

Keywords: Aspergilloma, culture, fine needle aspiration cytology, granulomatous inflammation


How to cite this article:
Mahendra N, Ingle A, Momin MA, Rehman SA, Borad DK. Isolated soft-tissue aspergilloma at the right lateral side of nose mimicking as tuberculoma. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:123-5

How to cite this URL:
Mahendra N, Ingle A, Momin MA, Rehman SA, Borad DK. Isolated soft-tissue aspergilloma at the right lateral side of nose mimicking as tuberculoma. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2021 Dec 2];23:123-5. Available from: https://www.sjohns.org/text.asp?2021/23/3/123/327570




  Introduction Top


Aspergilloma caused by fungus Aspergillus. Aspergillus fungus is ubiquitous and found in soil, decaying vegetation, and dust. Exposure to the fungus is through the respiratory tract but clinical presentation results from either from an aberrant immunologic response or tissue invasion. The lungs, sinuses, and brain are the organs most commonly involved.[1] Aspergilloma affecting areas of the body other than the lungs is called extrapulmonary aspergilloma.

Tuberculosis (TB) has worldwide presence and the most common affecting organ is lungs, while approximately 10% of TB cases have head-and-neck manifestation.[2] Granulomatous inflammation is typical of reaction to poorly digestible agents elicited by TB, sarcoidosis, actinomycosis, leprosy, syphilis, Wegner's granulomatosis, and foreign-body granulomas.[3] Imaging study helps to localize the lesion, to detect erosions and infiltrations but fails to differentiate soft tissue density from infective or malignant lesions.

Fine-needle aspiration cytology (FNAC) plays a crucial role in the diagnosis of the isolated nodular lesion with or without imaging guidance. In countries with high incidence of TB, TB is considered first in the differential diagnosis of granulomatous disease. Here, we report a case which was initially thought of tuberculoma; however cytological features, Gomori methenamine silver (GMS) staining, and culture confirmed the diagnosis of aspergilloma.


  Case Report Top


A 55-year-old male presented to our Ear, Nose, and Throat (ENT) outpatient department with chief complaints of nodular swelling on the right side of the nose for 6 months. Swelling was painless and gradually increasing in size. Clinical examination revealed a smooth to firm swelling below the medial canthus on the lateral aspect of the right side of the nose. It was 3 cm × 3 cm in dimension, nontender, and overlying skin did not show any signs of inflammation [Figure 1]a. Anterior rhinoscopy showed no obvious swelling in the nasal cavity. Throat and ear examinations were normal.
Figure 1: (a) Nodular swelling lateral aspect of the right side of the nose below medial canthus (red arrow). (b-d) Contrast-enhanced computed tomography Nose and paranasal sinuses (coronal view) showed heterogeneous soft tissue density in the right nasolabial fold region (green arrow) with mild pressure effects over adjacent nasal bone

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Outside laboratory investigations including hematological findings showed a normal hemogram with erythrocyte sedimentation rate of 30 at the end of 1 h. Coagulation tests including prothrombin time, activated partial thromboplastin time, and fibrinogen were within the normal limits. Serology test results for human immunodeficiency virus, hepatitis B surface antigen, and hepatitis C antibody testing were nonreactive. The result of his Mantoux test was negative. Biochemical investigations revealed a normal liver function test and renal function test. Random plasma glucose was 160 mg/dl. FNAC report done outside was suggestive of granulomatous inflammation with many giant cells secondary to tuberculosis etiology.

Contrast-enhanced computed tomography (CECT) of the nose and paranasal sinuses performed in our hospital, showed soft tissue density lesion in the right nasolabial fold region extending to deeper plane with mild pressure effects over the adjacent nasal bone [Figure 1]b, [Figure 1]c, [Figure 1]d favoring infective versus neoplastic pathology.

Repeat FNAC performed from the same swelling yielded pus-like material which on microscopy showed granulomas composed of epithelioid cells [Figure 2]a, dense collection of polymorphs, nuclear debris, histiocytes, structures favoring narrow, branched and septate fungal hyphae [Figure 2]b, and many multinucleated giant cells [Figure 2]c seen. Smears stained with GMS stain showed dichotomous branching, hyphae with frequent septations seen [Figure 2]d and [Figure 2]e. Overall cytology smears were suggestive of suppurative granulomatous inflammation secondary to fungal etiology. Aspirated FNAC sample was also submitted for wet mount with 10% potassium hydroxide (KOH) and fungal culture. KOH mount was positive for fungal hyphae and fungal culture revealed the growth of Aspergillus flavus.
Figure 2: (a-c) Dense neutrophilic infiltration, granuloma (red arrow) and narrow, branched and septate hyphae (green arrow) and multinucleated giant cells (H and E). (d and e) Hyaline septate hyphae form with acute angle branching (GMS stain). (f) Complete resolution of nodular swelling

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CECT chest was performed which showed normal findings. The patient was diagnosed and treated as isolated aspergilloma with oral antifungal (Voriconazole) with close monitoring of plasma glucose and other lab parameters. Eight weeks of drug therapy resulted in complete resolution of the swelling [Figure 2]f with no evidence of recurrence.


  Discussion Top


Aspergillus is a common saprophyte living in the soil and plants, transmitted to humans by inhalation. The mode of infection in extrapulmonary soft tissue mycosis is not well understood but has been suggested that implantation of fungus by insects, contamination from vegetation, and inoculation from patient's fingernails could be some of the possible factors. In general predisposing factors for fungal infections includes immunosuppressants, acquired immune deficiency syndrome, extensive antibiotics use, hematological malignancies, and debilitating conditions such as uncontrolled diabetes.[4]

The conidia of Aspergillus organisms germinate into hyphae and B-glucans present in the cell wall of these hyphae along with other ligands can precipitate an inflammatory response. The enzymes released by this organisms result in tissue necrosis and invasion. Clinical symptoms depend on the fungal strained and the immune status of the host.[5] The granuloma formation is related to disorder in the immune system, in which inability of the immune system to produce reactive oxygen species to kill the invading organisms like Aspergillus. The granuloma formation tries to localize and prevent an infective agent by walling it off with compact aggregates of histiocytes and thus preventing its spread in the body.[6]

Differential diagnosis of nodular swelling lateral aspect of the nose, as the one presented in this case, includes dermoid cyst, TB, neurofibroma, schwannoma, and cysticercosis. Hallmark of diagnosis is surgically excised histopathological findings but FNAC is a simple, rapid, economical, and less invasive diagnostic method for the diagnosis of nodular swelling. Aspirated material collected from multiple passes during FNAC is further useful for special stain, culture, and for cell block preparation.[7]

Hematoxylin and Eosin (H and E) stain, papanicolaou stain (PAP) AND May-Grunwald stain(MGG) widely used for FNAC aspirated samples cytosmears. On many occasions, epithelioid cell clusters, giant cells, dense collection of neutrophils with or without caseous necrosis overshadows the sparsely distributed fungal element treatment resulted in erroneous reporting of the chronic granulomatous lesion, and the tendency of the not investigating further is justified the high prevalence of TB in developing countries. Therefore, the patient is often subjected to anti-TB treatment due to cytopathological findings presumption.[8] In our case too, microscopic fungal element was missed by previously done FNAC and granulomatous inflammation was labeled as tuberculosis. The presence of fungal elements in repeat FNAC directed pathologist toward initiating a workup for fungal infections and avoiding unnecessary further investigations.

Treatment of soft tissue fungal infection is controversial, both medical and surgical modalities have been undertaken. However, in cutaneous disease, surgical excision alone and in some cases in combination with drug therapy has found to be curative. Voriconazole is an extended-spectrum triazole that has now become the treatment of choice for aspergillosis.[9] In our patient, medical treatment was preferred over surgical because of the location of swelling, to avoid surgical and cosmetic-related complications. An oral 6 weeks of voriconazole treatment resulted in a complete resolution of nodular swelling without recurrence.


  Conclusion Top


Aspergilloma at the lateral aspect of the nose is a very rare to encounter and poses clinical challenge. FNAC is an economical, less time-consuming, and minimally invasive diagnostic tool to diagnose soft-tissue lesion with or without imaging guidance. Although in countries with a high incidence of TB, all granulomatous inflammation are not TB. High index of clinical suspicion, careful microscopic cytological examination with the application of special stain should be employed to rule out fungal etiology and to avoid unnecessary drug usage, side effects, and treatment cost.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dennig DW. Aspergillus species. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. 5th ed., Vol. 2. Churchill Livingstone: Pennsylvania; 2000.  Back to cited text no. 1
    
2.
Swain SK, Sahu MC. Tubercular otitis externa in an elderly male - A case report. Iran J Otorhinolaryngol 2019;31:127-30.  Back to cited text no. 2
    
3.
Mohan H. Textbook of Pathology. 5th ed. India: jaypee brothers Medical publishers; 2006.  Back to cited text no. 3
    
4.
Lasisi OA, Nwarogu OG, Akang EU. Sinus mycosis - A case of persistent chronic sinusitis (case report). Niger J Surg 1997;4:77-80.  Back to cited text no. 4
    
5.
Rementeria A, López-Molina N, Ludwig A, Vivanco AB, Bikandi J, Pontón J, et al. Genes and molecules involved in Aspergillus fumigatus virulence. Rev Iberoam Micol 2005;22:1-23.  Back to cited text no. 5
    
6.
Chakrabarti A, Sharma SC, Chandler J. Epidemiology and pathogenesis of paranasal sinus mycoses. Otolaryngol Head Neck Surg 1992;107:745-50.  Back to cited text no. 6
    
7.
Samantaray S, Panda S, Dash S, Rout N. Role of fine-needle aspiration cytology in diagnosis of disseminated histoplasmosis in an immunocompetent patient: A case report. J Cytol 2017;34:156-8.  Back to cited text no. 7
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8.
S Chavan S, Bhople KS, Deshmukh SD, V Jain P, Sonavani M. Chronic invasive fungal granuloma - A diagnostic dilemma in an immunocompetent host. Iran J Otorhinolaryngol 2016;28:83-8.  Back to cited text no. 8
    
9.
Lat A, Thompson GR 3rd. Update on the optimal use of voriconazole for invasive fungal infections. Infect Drug Resist 2011;4:43-53.  Back to cited text no. 9
    


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