A 50-year-old female, with history of allergic rhinitis, presented with nasal obstruction, purulent nasal discharge from right side, cough, headache, and sneezing. She had completed a 10-day course of doxycycline with minimal symptomatic improvement. She was not a known case of diabetes, hypertension, bronchial asthma, or pulmonary tuberculosis. There was no history of previous surgery, facial trauma, distant travel, or drug abuse. On physical examination, a purulent discharge was noted in the right middle meatus. The left middle meatus was clear. The remaining examination of the head and neck revealed no significant findings. Her hemoglobin was 15.3 g/liter, her hematocrit was 0.45, and the leukocyte count was 7.4 × 109/liter with a normal leukocyte differential. The chest X-ray was unremarkable. A bone density-computed tomography revealed extensive opacity of the right maxillary sinus as well as erosion of the nasal wall and maxillary bone. The patient underwent right-sided functional endoscopic sinus surgery with opening of the right maxillary sinus. Thick mucus was present in the right maxillary sinus. The material was removed and sent for culture and histological examination. No antifungal agents were prescribed at that point in time. After 5 days, the patient came with complaint of bleeding from the right nostril. Right nostril was packed using a roller gauze and left nostril with IVALON nasal pack. Clots were visualized in B/L maxillary antrum using 30-degree scope, which were suctioned out. Mucosa was found to be healthy. No active anterior or posterior nasal bleeding. Patient was stable and asymptomatic and discharged.\nSpecimens sent for histological studies showed extensive eosinophilic infiltration with Charcot-Leyden crystals. There was no tissue invasion. Examination after Periodic Acid Schiff (PAS) staining showed septate, nondichotomously branching fungal hyphae (). Direct microscopy of a KOH preparation of the surgical specimen showed the presence of hyaline septate hyphae (). Culture at 27°C and 37°C on Sabouraud's dextrose agar containing gentamicin yielded a rapidly growing, white to pale buff, densely woolly fungus with a pale-brown reverse. It produced a strong disagreeable odor. There was no growth on medium containing cycloheximide. No bacteria were isolated under aerobic or anaerobic conditions. Microscopic examination of the mold showed hyphae of various widths. The isolate was held for several months and subcultured on different media, but it failed to sporulate under any conditions. Banana peel culture after 8 weeks showed macroscopically visible fan-shaped fruiting bodies (). LPCB mount of the same revealed hyaline septate hyphae, often with clamp connections or lateral pegs (, inset). Identification was confirmed by the presence of clamp connections formed on the hyphae and by vegetative compatibility with known isolates. Further study showed the isolate to be tolerant of benomyl (2 μg/mL), consistent with this basidiomycete [].
A 38-year-old male presented with a cough for 3 days, hemoptysis, fevers, and chills for 1 day (). He denied cough, fevers, night sweats, or weight loss prior to 3 days before admission. He had emigrated to the U.S.A. from Mexico seven years previously and had no foreign travel subsequently. In his previous life, he had worked as an automobile mechanic, in construction, and gardening. His past medical history indicated treatment for a lung infection, with an inability to work, 9 years previously, but he did not recall the diagnosis. During that time, he was treated concurrently with 3 different types of medications for 7 months but was never told that he had tuberculosis. He had no history of risk factors for an anaerobic lung abscess, such as aspiration, alcohol use, smoking or seizures.\nOn admission, his temperature was 39.4°C, leukocyte count was 6500/mm3, and HIV test was negative. Therapy with piperacillin-tazobactam and vancomycin was initiated and the patient remained hospitalized for 2 weeks. Computed tomography of the lung on hospital day 2 demonstrated an 8.2 × 5.5 cm cystic structure in the left upper lobe with an internal air-fluid level, fluid debris levels and a thick, irregular wall, consistent with a pulmonary abscess. There were surrounding areas of “ground-glass” opacities and consolidation in the left upper and lower lobes. Sputum cultures grew methicillin-susceptible Staphylococcus aureus and Klebsiella oxytoca, prompting discontinuation of vancomycin on hospital day 8. On hospital day 9, transthoracic left upper lobe pulmonary abscess drainage was performed, with an aspiration of 140 cc of dark green–black fluid. Cytologic examination of the aspirated fluid did not show malignant cells, but had abundant neutrophils, numerous erythrocytes, and necrotic debris. Smear and culture for mycobacteria, and anaerobic culture, were negative. Fungal culture yielded two colonies of a filamentous non-sporulating fungus. The therapy was then switched to oral amoxicillin-clavulanate. At discharge, his cough had improved and he denied dyspnea.\nAfter discharge, he reported two weeks of mild intermittent dyspnea, but otherwise remained asymptomatic. The amoxicillin-clavulanate therapy was discontinued. However, serial chest radiographs demonstrated a persistent air-fluid level within a thin-walled cystic structure in the posterior left upper lobe. These radiographs were unchanged for four months. He reported two weeks of mild, intermittent dyspnea in the 4th-month post-discharge.\nA chest tomogram performed 5 months post-discharge, to better characterize the disease, revealed a thin-walled cystic cavity in the left upper lobe apical posterior segment, measuring 5.0 × 4.6 cm. The fluid within the lesion was hyperdense, and there was a calcified component posteriorly. Cephalad to the lesion, there was an architectural distortion and bronchiectasis with adjacent scarring and likely adjacent cicatricial emphysema. The oblique fissure was displaced anteriorly, posterior to this region, secondary to the associated volume loss and/or scar. There was less consolidation in this area compared to prior tomograms.\nA sputum bacterial culture was unremarkable, sputum smear for parasites was negative, as were antibody tests for Histoplasma, Coccidioides (IgG and IgM), and Echinococcus, and 2 blood cultures. A test for HIV was again negative. Sputum fungal culture grew Candida albicans and a filamentous fungus, morphologically similar to the previously isolated fungus. With a diagnosis of a persistent abscess, he proceeded to left upper lobectomy and extensive lysis of pleural adhesions. He was hospitalized 8 days, during which time he had intermittent fevers. Initially, there was a mild leukocytosis, which subsided. The intra-operative findings revealed an abscess that was located deep within the posterior aspect of the left upper lobe. The posterior fissure was completely fused and required extensive dissection. Intra-operative cultures were positive for a fungus, identified by sequencing as Gloeostereum sp. This was morphologically similar to the filamentous fungus that had been cultured on the previous occasions. Susceptibility testing of the fungus by macrobroth dilution indicated low MIC to amphotericin B (0.5 µg/ml), but high to voriconazole (MIC of >8 µg/ml) and fluconazole (MIC 16 µg/ml). Candida albicans was not cultured in the specimen, nor seen in the histopathology. No antifungal chemotherapy was given.\nHistopathology of the resected specimen was interpreted as chronic inflammation in a bronchogenic cyst with a lining of ciliated pseudostratified columnar epithelium, some muscle and fibrous tissue, subepithelial chronic inflammation and pulmonary congestion (). The cyst contents showed fungal hyphae (). The fungus was sent to the Westerdijk Fungal Biodiversity Institute for definitive speciation and deposited there under number CBS 145006. The patient was seen in clinic 2 weeks post-discharge, at which time he denied fevers, chills. He remained well in subsequent visits.