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IMAGES IN PATHOLOGY
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 35-37

Aspergillosis of larynx with involvement of epiglottis in immunocompetent patient, a rare observation


Department of Microbiology, Smt Kashibai Navale Medical College and Hospital, Narhe, Pune, India

Date of Web Publication9-Apr-2012

Correspondence Address:
Archana B Wankhade
Department of Microbiology, Smt. Kashibai Navale Medical College and Hospital, STES Narhe Campus, Off Pune-Banglore Westerly bypass highway, Narhe Ambegaon, Pune - 411 041, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-9748.94732

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   Abstract 

A rare case of aspergillosis of larynx with involvement of epiglottis and subglottic region in immunocompetent patient is described in this study. A 65-year old male was presented with complain of upper airway obstruction, difficulty in swallowing, and hoarseness of voice. Presentation was similar to malignancy. Microbiological diagnosis was made by isolation and identification of Aspergillus fumigatus from the specimen. This diagnosis changed the treatment to antifungal drugs in day-by-day deteriorating patient. Patient responded dramatically to the antifungal therapy. Despite various radiological, histopathological investigations, microbiological reports supported clinicians in early and correct management of the case to prevent the development of serious complications.

Keywords: Aspergillosis, Aspergillus fumigatus, epiglottitis


How to cite this article:
Ghadage DP, Wankhade AB, Mali RJ, Bhore AV. Aspergillosis of larynx with involvement of epiglottis in immunocompetent patient, a rare observation. J Laryngol Voice 2012;2:35-7

How to cite this URL:
Ghadage DP, Wankhade AB, Mali RJ, Bhore AV. Aspergillosis of larynx with involvement of epiglottis in immunocompetent patient, a rare observation. J Laryngol Voice [serial online] 2012 [cited 2021 Sep 25];2:35-7. Available from: https://www.laryngologyandvoice.org/text.asp?2012/2/1/35/94732


   Introduction Top


Aspergillus infection is commonly observed in plants, animals, and birds, also pathogenic to human beings. The majority of human illnesses are caused by Aspergillus fumigatus and Aspergillus niger. Commonest mode of transmission is through inhalation of fungal spores. Fungus may also gain entry to the body tissue through wound or during surgery. [1] Invasion of epiglottis, trachea, and larynx due to fungal agents is rare incidence. For immunocompetent individuals, itrogenic factors, vocal abuse vocal fold cyst are predisposing factors. [2] The usual causative agents of epiglottitis are bacteria.


   Case Report Top


A 65-year-old male patient was admitted in emergency with upper airway obstruction, difficulty in breathing, throat pain, and difficulty in swallowing, change in voice since five days that rapidly evolved to stridor. There was no history of trauma. Currently, patient is working as watchman since 10 years. But, earlier patients had worked in cotton mill for 20 years. Blakish colored mass (slough or necrotic material) was seen with fiber optic laryngoscopy in subglottic region and which was later progressed into epiglottis. The differential diagnosis made by clinicians was diphtheria, subglottitis, growth, hematoma, and foreign body. The patient was put on respiratory supports. Emergency tracheostomy was performed. Tazobactam and metronidazole therapy was started.

Meanwhile, specimen from the lesion was received for bacteriological culture in microbiology laboratory. It was cultured on Blood agar and MacConkeys medium. Gram stain showed moderate number of polymorphonuclear leukocytes with septate setate hyphae with dichotomous branching [Figure 1]. Later on, KOH (10%) mount of direct specimen was done which showed hyaline septate hyphae having diachotomous branching at acute angle [Figure 2]. The sample was cultured on Sabroud's dextrose agar (SDA) and SDA with chloramphenicol and actidione. After 24 hours on SDA, colonies were white turning to smoky green velvety powdery [Figure 3]. The reverse was white to tan after 48 hours. Fungal colonies were also seen on blood agar after 24 hours. Tease mount of colony on SDA with lactophenol cotton blue showed septate hyphae with the short smooth unbranched conidiophores arising from foot cells. Phialides with single uniseriate, sterigmata on upper half of vesicle parallel to axis of stalk were seen [Figure 4] which is identified as A. fumigatus.
Figure 1: Hyaline septate hyphae in KOH mount preparation (400X)

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Figure 2: Gram stain showing septate hyphae with acute angle branching with polymorphonuclear cells in the tissue (1000X)

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Figure 3: SDA with white turning to smoky green velvety powdery colonies

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Figure 4: LPCB mount showing conidiophores, vesicles, and conidia of Aspergillus flavus (400X)

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Next day, pus sample from tracheostomy tube showed similar microscopy and culture findings. Microscopic findings were characteristics of fungal infection and were reported to otolaryngology department. On the basis of this report, oral antifungal drug fluconazole 150 mg was given to this patient. The patient showed marked improvement within a week. Later on, diagnosis was confirmed as Aspergillus on culture. As this patient responded to fluconazole, no change in treatment was made.

Later on, histopathological analysis also showed the findings suggestive of aspergillosis which exactly correlates with our findings. CT showed echogenic irregular lesion noted at the level of glottis and diagnosis was growth and hemorrhage. Chest X-ray was normal. Investigations showed hemoglobin level, 8.8 g/dl; WBC, 54 700 cells/cumm with neutrophilia. Blood sugar level was within normal limit. HIV test was also done to know the immune status of the patient (with informed consent) and it was found to be non-reactive. Other routine investigations were within normal limit. There was no history of asthama and the patient was not on steroids.

He had responded well to the antifungal drug because when the third sample from the same site was received after antifungal therapy for a week, there were scanty fungal hyphae seen in 10% KOH mount. Bronchoscopy of the patient was also done. Bronchoalveolar lavage revealed no fungal elements.


   Discussion Top


There is report of few cases of laryngeal localization of Aspergillosis of tracheobronchial tree. In present case of laryngeal Aspergillosis, epiglottis and subglottic region were predominantly invaded. Epiglottis when swollen, it can cause serious breathing difficulties and is a medical emergency.

In the present case, the differential diagnosis done by clinicians were hematoma, diphtheria, and malignancy which were associated with epiglottitis but not with fungal infection. Differential diagnosis is important as the clinical symptoms are similar to those of malignancy. Makitie et al. [3] reported the laryngeal infection with marked resemblance to laryngeal carcinoma, suggesting that fungal infection may present with features similar to malignancy. Kim et al. [4] reported aspergillosis resembling as vocal cord cyst. One of the aims of reporting this case is to highlight the fact to consider fungal infection of larynx as the differential diagnosis while managing a patient of acute epiglottitis and malignancy. This is very important as the management protocol changes significantly as per the diagnosis.

Fungal hyphae of A. fumigatus were seen in direct specimens and also observed in repeated samples. Direct demonstration of the septate hyphae of A. fumigatus and isolation in repeated culture substantiated the significance of clinical isolates in culture and ruled out the possibility of contaminating A. fumigatus seen in the culture. [5] A. fumigatus was repeatedly isolated from the lesion in present case. Repeated demonstration in the direct smear as well as culture establish the diagnosis of aspergillosis beyond doubt. [5] Aspergillosis was also confirmed on histopathological examination of biopsy. In a study, Nakahira et al. [6] also observed laryngeal aspergillosis on culture of biopsy.

Invasive aspergillosis is an opportunistic infection with a high mortality rate that usually occurs in the immunocompromised host. Medical literature suggests that this fungus is manifesting commonly in the immunocompromised and rarely in immunocompetent. Gupta et al. [7] reported the case of invasive Aspergillosis with an invasion of lungs, lymph node, and esophagus in an immunocompetent patient. Yong Cai Liu et al. [2] reported two cases of laryngeal Aspergillosis in immunocompetent patients.

Initially, the patient was on tazobactam and metronidazole and was not responding to these drugs. Condition of patient was deteriorating day by day. After reporting of A. fumigatus by microbiology department, the treatment was changed to Fluconazole. Patient responded well to antifungal therapy which further confirmed the cause of infection was A. fumigatus.

To summaries, this case highlighted an atypical example of a fungal aspergillosis of larynx with involvement of epiglottis in adult immunocompetent patient with no history of fungal infection. This case report suggests that Aspergillosis is potential cause of epiglottitis even in immunocompetent patient.

 
   References Top

1.Bolivar R, Gomez LG, Luna M, Hopfer R, Bodey GP. Aspergillus epiglottitis. Cancer 1983;51:367-70.  Back to cited text no. 1
    
2.Liu YC, Zhou SH, Ling L. Aetiological factors contributing to the development of primary laryngeal aspergillosis in immunocompetent patients. J Med Microbiol 2010;59:1250-3.  Back to cited text no. 2
    
3.Mäkitie AA, Bäck L, Aaltonen LM, Leivo I, Valtonen M. Fungal infection of the epiglottis simulating a clinical malignancy. Arch Otolaryngol Head Neck Surg 2003;129:124-6.  Back to cited text no. 3
    
4.Kim YI, Park BC, Lee JS, Min HK. A case of primary laryngeal aspergillosis confused with vocal cyst. Korean J Otorhinolaryngol Head Neck Surg 2010;53:726-8.  Back to cited text no. 4
    
5.Chander J. Textbook of Medical Mycology. 3 rd ed. Mehta Publisher; 2009.  Back to cited text no. 5
    
6.Nakahira M, Saito H, Miyagi T. Left vocal cord paralysis as a primary manifestation of invasive pulmonary aspergillosis in a nonimmunocompromised host. Arch Otolaryngol Head Neck Surg 1999;125:691-3.  Back to cited text no. 6
    
7.Gupta S, Katkar A, Byotra SP, Prakash V. Invesive aspergillosis in an immunocompetent host. JK Sci 2004;6:103-5.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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