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 76-year-old male presented to our institution with chronic cough and intermittent haemoptysis for 2 months. He had completed standard anti-TB therapy 10 years prior for smear positive cavitatory pulmonary Mycobacterium tuberculosis. Other past medical history was significant for rheumatic fever. He was a lifelong non-smoker. Thoracic computed tomography (CT) done 7 years previously demonstrated traction bronchiectasis and chronic scarring within the right upper lobe. He remained symptomatically well until this presentation.\nHis physical examination revealed bronchial breath sounds in the right upper lobe. Thoracic CT demonstrated fibrocystic change in an incompletely collapsed right upper lobe. There was now a large cavity with a new 2.1-cm round mass (Fig. A, C).\nWe proceeded to perform flexible bronchoscopy (Olympus 3.2 mm) under conscious sedation. After traversing two segments of the bronchi, an abnormal rounded mass was seen obstructing the anterior segment of the right upper lobe (Fig. A). Microbiological culture of bronchoalveolar lavage (BAL) from the right upper lobe cavity subsequently isolated both Staphylococcus aureus and Aspergillus fumigatus. He was commenced on a one week course of flucloxacillin as well as a prolonged course of the anti-fungal drug posaconazole. He was subsequently discharged and electively readmitted a few weeks later to facilitate bronchoscopic removal of the mycetoma.\nAt repeat flexible bronchoscopy, a flexible cryoprobe was inserted via the bronchoscope into the cavity. However, en bloc removal of the mass was not possible. The cryoprobe was removed and hot forceps was introduced to subdivide the mass into various smaller parts. Then the cryoprobe was reintroduced and the subdivided mass was removed piecemeal. Washing of the cavity was then performed with normal saline until all macroscopically visible mycetoma had been removed. Inspection of the empty cavity revealed inflamed haemorrhagic mucosa (Fig. B).\nThe obtained mass was sent for histopathological analysis. Microscopically, it demonstrated inflamed bronchial mucosa, abundant fungal organisms as well as a bacterial colony consistent with Gram-positive cocci. There was no evidence of invasive fungal infection. The case was discussed at our institution's multidisciplinary respiratory meeting, where a diagnosis of mycetoma was inferred. He was continued on oral posaconazole. Radiological and bronchoscopic surveillance at 3 months demonstrated no reoccurrence of the mycetoma (Figs. B, B, D).