Fungal rhinosinusitis (FRS) comprises subtypes with varying epidemiology and outcomes. Global comparative data remain limited. Following PRISMA guidelines (CRD42023481670), a systematic review and meta-analysis was conducted. Cases were categorized into seven subtypes to assess variation across regions. 2,031 studies (40,860 cases, 77 countries) were included. Non-invasive forms accounted for 60% (n=24,582) of cases, mainly fungal ball (35%, n=14,280) and allergic FRS (25%, n=10,302). Invasive subtypes were more frequent in tropical climates, with the hyperacute rhino-orbito-cerebral mucormycosis predominating. This subtype differed from acute and subacute invasive FRS in risk factors (diabetes and COVID-19 vs. leukemia) and geography. Aspergillus species appeared in ~60% of cases: A. fumigatus dominated in temperate/continental zones, while A. flavus was frequent in dry/tropical regions. Non-invasive FRS showed high surgical cure rates (>64%), whereas invasive forms had substantial morbidity and mortality. FRS represents a substantial yet underrecognized global health concern. Non-invasive forms are predominating, while invasive subtypes cause major morbidity and mortality, especially in tropical regions. Notably, our findings reveal distinct geographic and climatic preferences for Aspergillus species: A. fumigatus in temperate/continental zones and A. flavus in dry/tropical regions. This ecological divergence underscores the importance of environmental surveillance and climate-informed diagnostic strategies.

Chronic pulmonary aspergillosis involves the formation of a fungal ball (aspergilloma) in lung cavities. Pseudomonas aeruginosa commonly co-colonizes these lesions; however, the in vivo mechanisms underlying its persistence are unknown. Using a multi-omics approach on resected aspergillomas, we defined the genomic, transcriptional, and metabolic adaptations of P. aeruginosa within this polymicrobial niche. We reconstructed high-quality P. aeruginosa genomes and identified a conserved core genome, along with accessory genes for secondary metabolism, virulence, and antimicrobial resistance. Phylogenomics revealed heterogeneous evolutionary paths among co-colonizing strains. Metatranscriptomics showed stark physiological heterogeneity, from metabolically aggressive to stress-adapted states. High expression of phenazine, quorum-sensing (PQS), siderophore, and secretion-system operons was corroborated by metabolomic detection of phenazine-1-carboxylic acid and 2-heptylquinolin-4(1H)-one, confirming active bacterial antagonism in vivo. Concurrent Aspergillus fumigatus transcriptomics revealed the activation of oxidative stress responses, secondary metabolism (eg fumagillin), and iron scavenging, demonstrating reciprocal competition. Host transcriptomics revealed patient-specific immune signatures that correlated with the metabolic activity of the co-colonizers. This work provides an integrated systems-level analysis of the tri-kingdom aspergilloma ecosystem. P. aeruginosa persistence is driven by genomic plasticity and context-dependent expression of competitive pathways, shaped within a chronic inflammatory environment. These findings redefine aspergillomas as active polymicrobial consortia, establishing a framework for targeting resilient microbial communities in chronic lung disease.

Fungal balls (aspergillomas) are a debilitating complication of chronic pulmonary aspergillosis, but their functional biology as multi-kingdom ecosystems is poorly understood. Through integrated multi-omics analysis of 61 patient-derived fungal balls, we reveal their complex ecology. While Aspergillus fumigatus dominates the fungal niche (59% of patients), bacterial co-colonization is ubiquitous, primarily by Pseudomonas aeruginosa and Haemophilus influenzae. Metabolomics and metatranscriptomics unveil a structured division of labor and active warfare, including metabolic cross-feeding, competition for iron, and reciprocal antagonism via secondary metabolites, such as fumagillin and fumigaclavine C produced by A. fumigatus. Host metabolomics and transcriptomics revealed a potent but dysregulated human immune response, characterized by neutrophil activation and failed resolution. Our findings redefine aspergilloma not as a mere fungal aggregate, but as a resilient polymicrobial biofilm across kingdoms, in which synergistic and antagonistic inter-kingdom interactions drive pathogenesis and chronicity, suggesting new therapeutic strategies targeting the pathogenic consortium.IMPORTANCEChronic pulmonary aspergillosis (CPA) and its hallmark fungal balls (aspergillomas) represent a debilitating and difficult-to-treat respiratory disease, affecting millions worldwide. Here, we provide the first integrated multi-omics profile of surgically resected fungal balls from 61 CPA patients, revealing these structures not as mere fungal colonies, but as resilient, cross-kingdom biofilms teeming with bacterial co-colonizers, particularly Pseudomonas aeruginosa and Haemophilus influenzae. Our findings uncover a dynamic battlefield where fungi and bacteria engage in metabolic cross-feeding, chemical warfare, and competition for nutrients such as iron. We demonstrate that the host mounts a potent but dysregulated immune response characterized by chronic neutrophilic inflammation and failed resolution, driving tissue damage and disease persistence. Our data provide a foundation for novel therapeutic strategies aimed at disrupting microbial synergy, modulating host inflammation, and breaking the cycle of chronic infection, an approach that could significantly improve outcomes for patients with this refractory disease.

Maxillary sinus marginal calcification: A novel radiological entity distinct from maxillary sinus fungal ball.

Bladder fungal ball formation is a rare type of fungal infection, most commonly occurring in patients with diabetes or immunodeficiency. Only a few reports have described bladder fungal balls detected on computed tomography (CT). This case presentation highlights the characteristic CT findings of bladder fungal balls and discusses the diagnostic challenges. A 66-year-old male was admitted with complains of passing particulate matter in urine, urinary frequency, urgency, and hematuria. He had a long-standing history of diabetes and hypertension. Nonenhanced abdominal CT revealed multiple bladder nodules with mixed density, the largest measuring approximately 2.5 cm in diameter, accompanied by signs of emphysematous cystitis. The nodules exhibited a peculiar appearance. Pathological examination of expelled material and urine culture confirmed Candida species infection. The patient received intravenous fluconazole for fungal urinary tract infection (400 mg daily) and intensive insulin therapy for critically high fasting blood glucose (23.31 mmol/L). After 10 days of treatment, follow-up CT showed a reduction of bladder gas shadows but enlargement of the nodules, filling the entire bladder lumen. Despite improved glycemic control, the patient refused further intervention (e.g., cystoscopic evacuation) and was lost to follow-up. In high-risk patients (e.g., diabetes), the CT finding of multiple irregular bladder nodules with associated emphysematous cystitis should raise strong suspicion for bladder fungal balls, prompting timely urine culture and appropriate antifungal therapy.

Postnasal Drip and Antrostomy Narrowing after Surgery for Maxillary Sinus Fungus Ball.

Infectious complications are a leading cause of morbidity and mortality post-lung transplantation. Chronic rhinosinusitis (CRS) frequently occurs in patients with conditions that are common indications for lung transplantation. Proactive management of sinonasal disease may help to reduce airway colonization and improve clinical outcomes after lung transplantation, but CRS prevalence, clinical features, and management strategies in lung transplant recipients are poorly studied. Thus, we sought to clarify the prevalence, clinical characteristics, and management strategies of chronic rhinosinusitis (CRS) among lung transplant recipients at a single lung-transplant center in Japan, with particular attention to regional differences in disease etiology and management. We included 272 patients who underwent or were scheduled to undergo lung transplantation at the University of Tokyo Hospital between 2015 and 2024. Patient demographics, underlying respiratory diseases, pre- or posttransplant sinonasal status, and otolaryngological management data were collected. CRS was diagnosed based on the EPOS 2020 criteria, which incorporate clinical symptoms, endoscopic findings, and radiological evidence. We evaluated CRS prevalence and its associations with specific pulmonary diagnoses, surgical intervention rates, and clinical outcomes. CRS was identified in 7.2 % (16/222) of pre-transplant and 13.8 % (8/58) of post-transplant patients. Significantly higher CRS prevalence was observed in patients with bronchiectasis (53.8 %, odds ratio [OR] 17.7, p < 0.001) and diffuse panbronchiolitis (60.0 %, OR 18.5; p = 0.005), suggesting that ciliary dysfunction is a major risk factor for CRS. Imaging predominantly revealed maxillary and ethmoid sinus involvement. Fungal balls were noted in approximately 10 % of patients. Endoscopic sinus surgery was performed in refractory CRS cases, which resulted in good postoperative outcomes, with preservation of lung graft function and absence of surgery-related complications and opportunistic infections. Although based on a limited number of surgical cases, histopathological examination of the surgical specimens revealed a predominance of neutrophilic and non-eosinophilic inflammation. CRS is a clinically significant and relatively common complication in Japanese lung transplant recipients, particularly in those with underlying ciliary dysfunction. These findings highlight distinct regional differences in disease phenotypes and management approaches for CRS in lung transplant recipients. Systematic otolaryngological evaluation and timely intervention for CRS, including endoscopic sinus surgery, may help to prevent severe infections and optimize post-lung transplant outcomes.

An aspergilloma is a fungus ball that forms within a preexisting cavity, most commonly in the lungs but also in the paranasal sinuses. It represents a chronic inflammatory disorder that can persist for months and cause life-threatening hemoptysis. In this study, we hypothesized that the fungus ball is predominantly composed of non-viable hyphae and that chronic inflammation is maintained primarily by host responses to these non-viable elements rather than by ongoing fungal proliferation. To investigate this, we created a murine fungus ball model by implanting heat-killed Aspergillus fumigatus fungus balls, allowing for ≥16 weeks of longitudinal assessment. The model recapitulated key pathological features of the human disease, including progressive fibrosis and sustained angiogenesis, coinciding with elevated vascular endothelial growth factor (VEGF). A distinct immune response was observed where neutrophils infiltrated the fungus ball core, while macrophages accumulated at the periphery. Strikingly, these macrophages surrounding the lesion progressively became lipid-laden foam-like cells with an M1-skewed profile, a phenomenon reproduced in vitro by exposure to non-viable hyphae alone. Thus, the fungal material itself can sustain chronic inflammation and vascular remodeling, implicating macrophage lipid accumulation as a process potentially contributing to the chronic host response. These findings highlight lipid dysregulation and failed fungal clearance as key features of the host-response disorder associated with the fungus ball and establish a tractable platform for evaluating host-directed therapies.IMPORTANCEAspergilloma, a fungus ball that forms in preexisting cavities of the lung or paranasal sinuses, can cause chronic symptoms and life-threatening bleeding. Current fungicidal treatments, including antifungals, are often ineffective, and surgery to remove the fungal ball is risky. To better understand why these lesions can persist even when active fungal growth is limited, we developed a murine subcutaneous fungus ball model using non-viable Aspergillus fumigatus. In this model, a fungal mass composed largely of non-viable hyphae was associated with chronic inflammation, neovascularization, fibrosis, and the accumulation of lipid-laden, foam cell-like macrophages around the fungus ball. These findings support the concept that persistent non-viable fungal material can sustain key features of aspergilloma-like pathology through dysregulated host responses. They provide a conceptual rationale for future studies of host-directed strategies that modulate inflammatory and lipid-handling pathways in addition to conventional antifungal approaches.

Spore Wars: A Comprehensive Review of Pulmonary Aspergilloma and Its Clinical Management.

"Background: Fungal rhinosinusitis (FRS) comprises subtypes with varying epidemiology and outcomes. Global comparative data remain limited. Methods: Following PRISMA guidelines (CRD42023481670), a systematic review and meta-analysis was conducted. Cases were categorized into seven subtypes to assess variation across regions. Results: 2,031 studies (40,860 cases, 77 countries) were included. Non-invasive forms accounted for 60% (n=24,582) of cases, mainly fungal ball (35%, n=14,280) and allergic FRS (25%, n=10,302). Invasive subtypes were more frequent in tropical climates, with the hyperacute rhino-orbito-cerebral mucormycosis predominating. This subtype differed from acute and subacute invasive FRS in risk factors (diabetes and COVID-19 vs. leukemia) and geography. Aspergillus species appeared in ~60% of cases: A. fumigatus dominated in temperate/continental zones, while A. flavus was frequent in dry/tropical regions. Non-invasive FRS showed high surgical cure rates (&gt;64%), whereas invasive forms had substantial morbidity and mortality. Conclusions: FRS represents a substantial yet underrecognized global health concern. Non-invasive forms are predominating, while invasive subtypes cause major morbidity and mortality, especially in tropical regions. Notably, our findings reveal distinct geographic and climatic preferences for Aspergillus species: A. fumigatus in temperate/continental zones and A. flavus in dry/tropical regions. This ecological divergence underscores the importance of environmental surveillance and climate-informed diagnostic strategies."

A rare case of isolated frontal sinus fungus ball

Sphenoid Sinus Fungal Ball and Mucocele

Background. Pulmonary aspergilloma is the most common pulmonary involvement due to Aspergillus. It usually develops in a pre-existing cavity in the lung, most often due to tuberculosis. Hemoptysis occurs secondary to local invasion of the blood vessels lining the cavity. Recurrence of which, is an indication to do surgery, lobectomy in particular. Antifungals like amphotecin B given intravenously and itraconazole given orally, have been the traditional management. But with the emergence of newer antifungals, Echinocandins in particular, which functions to inhibit the β-(1,3) p-glucan synthase, an enzyme necessary for the synthesis of an essential component of the cell wall of fungi, one may need not undergo surgery. The most common antifungal medication for Aspergillus is voriconazole, a second-generation triazole. This case demonstrates the efficient utilization of Voriconazole along with Anidulafungin, which is necessary for the fungal cell wall integrity. For immunocompromised patients with pulmonary aspergilloma, this dual therapy presents a viable substitute for surgical intervention and an efficient treatment approach. Case. We present a case of a 54-year-old married patient, who presented with massive hemoptysis four days before consulting a private physician. She had ten episodes of hemoptysis four hours before admission and was rushed to the hospital. The patient had multiple comorbidities, including diabetes, hypertension, and asthma, contributing to an immunocompromised state. She had a history of anti-tuberculosis treatment in 2000, which was discontinued due to an allergic reaction. During her hospital stay, she experienced febrile episodes, and capillary glucose monitoring was beyond acceptable levels, prompting antibiotic initiation. A chest CT scan revealed pulmonary tuberculosis with cicatricial atelectasis of the lingular segment and infected cavitary formation. A bronchoscopy and biopsy of the cavitary lesion were scheduled. Surgical intervention, particularly lobectomy, was not pursued due to multiple factors, including the patient's immunocompromised status, her underlying comorbidities, and the response to antifungal therapy. After eight to 14 fourteen (8-14) hospital days, no episodes of hemoptysis were noted, and the biopsy result revealed fungal colonization consistent with Aspergillus species. The patient was discharged with oral Voriconazole and other maintenance medications. A repeat chest CT scan after five months of antifungal therapy showed regression of the fungus ball. Conclusion. In this case, pulmonary aspergilloma in an immunocompromised patient was successfully treated with a combination antifungal therapy utilizing anidulafungin and voriconazole. The favorable clinical response to dual antifungal therapy provides a feasible non-surgical alternative to surgical intervention, which has historically been the preferred option for treating recurrent hemoptysis, particularly in high-risk patients. The fungus ball's regression and the fungal infection's resolution support the growing role of more recent antifungal medications in the treatment of complicated pulmonary infections. This case suggests that echinocandins combined with triazole therapy are a viable less invasive treatment option for pulmonary aspergilloma than surgery. Keywords. Pulmonary Aspergilloma, Immunocompromised, Voriconazole, Anidulafungin, Fungus Ball, Dual Antifungal Therapy

Fungal rhinosinusitis comprises a heterogeneous group of diseases affecting the nasal cavity and paranasal sinuses, ranging from non-invasive colonization to rapidly progressive, life-threatening invasive infections. The clinical course and prognosis largely depend on the host immune status and the presence of tissue invasion, with invasive forms posing a high risk of orbital and intracranial complications. In recent years, the incidence of fungal rhinosinusitis has increased, likely due to improved diagnostic modalities, wider use of endoscopy, and a growing population of immunocompromised patients, including those with diabetes mellitus and post-COVID-19 conditions. This article provides a comprehensive review of fungal rhinosinusitis, focusing on current classification, epidemiology, pathophysiology, clinical manifestations, diagnostic strategies, and management principles. According to histopathological criteria, fungal rhinosinusitis is classified into non-invasive forms (saprophytic colonization, fungal ball, and allergic fungal rhinosinusitis) and invasive forms (acute invasive, chronic invasive, and granulomatous invasive fungal rhinosinusitis). Non-invasive disease typically affects immunocompetent individuals and is characterized by localized fungal accumulation or hypersensitivity reactions without tissue invasion, whereas invasive forms predominantly occur in immunocompromised patients and are associated with angioinvasion, tissue necrosis, and bone destruction. Diagnosis relies on a combination of clinical evaluation, endoscopic findings, radiologic imaging, and definitive histopathological confirmation. Computed tomography plays a key role in identifying hyperdense fungal material and bony changes, while magnetic resonance imaging is essential for assessing soft-tissue involvement and extrasinus extension. Management strategies vary according to disease type and include surgical intervention, systemic antifungal therapy, and correction of underlying predisposing factors. A clinical case of isolated sphenoid fungal rhinosinusitis with optic nerve compression is presented, illustrating the diagnostic challenges and therapeutic considerations. Successful treatment was achieved with endoscopic transnasal sphenoidotomy, followed by close postoperative surveillance. This case highlights the importance of early recognition, accurate diagnosis, and individualized management to prevent irreversible complications and ensure favorable outcomes.

ABSTRACTObjectivesWhile maxillary sinus fungal balls (MSFB) can be associated with odontogenic conditions (MSFBO), MSFBO clinical and dental features have not been compared to odontogenic sinusitis (ODS). This multicenter study aimed to compare characteristics of MSFB, MSFBO, and ODS.MethodsA multicenter international retrospective cohort study was conducted on adults with MSFBs and ODS who underwent sinus surgery. First in MSFBs, it was determined whether different dental conditions were more likely in FB versus non‐FB sides. Second, clinical features and dental pathologies were compared between MSFBO and ODS. For analyses, dental conditions were considered individually and as two groups: infectious pathologies and dental/oral procedures with indwelling metallic materials.ResultsAfter exclusions, there were 203 MSFBs and 163 ODS. Among MSFBs, 141 were MSFBOs. FB sides were associated with sinus protrusion of root canal treatment (RCT) materials (p = 0.040) and dental implants (p = 0.040). Compared to MSFBO, ODS patients were younger, more likely to have MS purulence (OR = 40.9, p < 0.010), more likely associated with apical periodontitis (OR = 2.59, p = 0.010) and oroantral fistulas (OR = 6.94, p = 0.020), and less likely associated with extruded RCT materials (OR = 0.01, p = 0.010) and protruded midface screws (OR < 0.01, p = 0.010). Comparing purulent MSFBO and ODS, ODS was more associated with infectious dental pathologies (p < 0.009).ConclusionCompared to MSFBs, MSFBOs were associated with RCT extrusion and implant protrusion. Compared to MSFBOs, ODS was more likely purulent and associated with infectious dental pathologies. While ODS is often distinct from MSFBO, the two conditions can coexist, and surgeons must determine whether patients have infectious dental pathology requiring treatment with both conditions.Level of Evidence4.

ABSTRACTPresented here is an extremely rare case of bilateral ureteral obstruction due to Candida albicans fungus balls, which led to acute kidney dysfunction and candidemia. An 83‐year‐old man was brought to our hospital after falling due to poor physical condition. He had been receiving abiraterone acetate for 1 month for metastatic castration‐resistant prostate cancer, while past medical history included type II diabetes, cardiovascular disease, and dementia. Blood test results revealed severe liver dysfunction, though whole‐body computed tomography (CT) findings showed no abnormalities. Based on the recent therapy course, the patient was diagnosed with drug‐induced liver damage caused by abiraterone acetate, and steroid pulse therapy and antibiotic administration were started. On Day 11 after starting that treatment, decreased urine output and renal dysfunction were noted. CT scanning revealed bilateral hydronephrosis and slightly dense masses at the origin of ureteral obstruction on both sides. Subsequently, C. albicans was detected in blood and urine samples, thus fungus balls were determined as the cause of bilateral hydronephrosis. Temporary hemodialysis was required, though clinical symptoms and biochemical findings gradually improved following insertion of bilateral ureteral stents and administration of antifungal therapy, and the patient was discharged 72 days after admission.

Sinonasal tumours are rare entities presenting with non-specific symptoms, therefore being often misinterpreted. The present study aimed to evaluate if the 13-gene DNA Methylation assay for early cancer detection already assessed in the oral cavity, was also useful in nasal cavity tumours. The case series consisted of 93 patients (63 males/30 females), 49 with malignant tumours, 14 with benign/borderline tumours, 34 as control series with 33 inflammatory polyps and one fungus ball. We collected one flocked swab from the lesion and one from the contralateral nasal cavity. All sinonasal cancer cases were evaluated by bisulfite next generation DNA sequencing, investigating the following genes: ZAP70, ITGA4, KIF1A, PARP15, EPHX3, NTM, LRRTM1, FLI1, MIR193, LINC00599, MIR296, TERT, GP1BB. To evaluate the performance of the methylation assay, a specific methylation score was calculated for each sample using linear discriminant analysis, with a predefined positivity threshold of 1.0615547. The association between diagnosis and methylation score positivity was evaluated through Fisher's exact test and calculation of risk ratios with 95% confidence intervals. Additionally, dimensionality reduction techniques were employed to explore the structure of the dataset and assess the ability of methylation profiles to distinguish between different pathological conditions. The 13-gene DNA Methylation scored positive in 42/49 malignant tumours; We included also 14 benign/borderline tumours of which 11 scored positive. Among 33 inflammatory polyps, 24 scored negative, as well as 64/70 normal contralateral mucosa and one fungus ball. Therefore, excluding benign/borderline tumours, the detected sensitivity was 85.7% and specificity 85.6% (AUC: 0.878).

The role of epithelial dysregulation is poorly understood in fungal sinusitis. We aimed to examine differential gene expression and quantify protease expression in sinonasal tissue from distinct patient cohorts, those with and without invasive fungal sinusitis (IFS). We hypothesized that abnormal epithelial integrity in the sinonasal mucosa of immunosuppressed IFS patients may allow for tissue invasion. Bulk RNA sequencing was performed on tissue from eight patients from two cohorts: immunosuppressed patients with and without IFS. Evaluation of protein expression for select proteases and their inhibitors was performed on all sinonasal tissues using multiplex western blotting. To expand upon these findings, protein expression of proteases and their inhibitors was evaluated in sinonasal tissue from eight patients with non-invasive fungal sinusitis (fungal ball). Bulk RNA sequencing identified 33 genes that were differentially regulated in immunosuppressed IFS tissue compared to those without IFS. Multiplex western blot revealed several proteases, including matrix metalloproteinases (MMPs), with increased expression in the immunosuppressed IFS cohort compared to the cohorts without IFS. Tissue inhibitors of MMPs (TIMPs) were proportionally lower in IFS patient tissue compared to the control cohorts, resulting in several abnormal IFS-related MMP/TIMP ratios. In the non-invasive fungal sinusitis cohort, unique MMP/TIMP ratios were dysregulated. Several proteases with increased expression in immunosuppressed IFS patients may be responsible for both an appropriate immune response to the pathogen as well as epithelial barrier breakdown and subsequent fungal invasion.

Pulmonary aspergillosis is a fungal lung infection caused by inhalation of Aspergillus spores. While traditionally associated with immunocompromised patients, it may also develop in immunocompetent individuals. The clinical presentation is wide, varying from asymptomatic colonization to invasive disease with significant morbidity. Despite advances in antifungal therapy with agents such as voriconazole, medical treatment alone often fails to achieve complete eradication of the infection, especially in cases of aspergilloma, where a dense fungal ball forms within a pre-existing pulmonary cavity. Surgical resection remains the mainstay management of localized aspergilloma. The type of surgery and how much tissue is removed are determined by the size and location of the lesion, as well as the patient's lung function. Traditionally, these operations have been performed via thoracotomy because of the complexity of the procedure and the possibility of intra-operative bleeding. However, recent developments in minimally invasive thoracic surgery, such as video-assisted thoracoscopic surgery, combined with comprehensive multidisciplinary management, offer a safer and less morbid alternative. This case demonstrates successful integration of multidisciplinary medical management, including antifungal therapy and minimally invasive surgical resection in treating a centrally located pulmonary aspergilloma.

Ectopic teeth in the maxillary sinus are an uncommon finding, and when symptomatic, often present as chronic rhinosinusitis. However, concurrent presentation with a fungal ball is exceptionally rare and scarcely documented in the literature. We report a unique case of a 39‐year‐old woman with recurrent maxillary sinusitis, ultimately diagnosed with coexisting ectopic tooth and fungal ball in the left maxillary sinus. The patient underwent successful endoscopic sinus surgery for simultaneous removal of both lesions. Postoperatively, she experienced complete resolution of symptoms without complications. This case highlights the diagnostic importance of imaging in refractory rhinosinusitis and demonstrates that endoscopic management is an effective and minimally invasive approach for this rare dual pathology.