Bloody Nasal Discharge Research Articles

2022 American College of Rheumatology/European Alliance of Associations for Rheumatology Classification Criteria for Granulomatosis With Polyangiitis.

To develop and validate revised classification criteria for granulomatosis with polyangiitis (GPA). Patients with vasculitis or comparator diseases were recruited into an international cohort. The study proceeded in 5 phases: 1) identification of candidate criteria items using consensus methodology, 2) prospective collection of candidate items present at the time of diagnosis, 3) data-driven reduction of the number of candidate items, 4) expert panel review of cases to define the reference diagnosis, and 5) derivation of a points-based risk score for disease classification in a development set using least absolute shrinkage and selection operator logistic regression, with subsequent validation of performance characteristics in an independent set of cases and comparators. The development set for GPA consisted of 578 cases of GPA and 652 comparators. The validation set consisted of an additional 146 cases of GPA and 161 comparators. From 91 candidate items, regression analysis identified 26 items for GPA, 10 of which were retained. The final criteria and their weights were as follows: bloody nasal discharge, nasal crusting, or sino-nasal congestion (+3); cartilaginous involvement (+2); conductive or sensorineural hearing loss (+1); cytoplasmic antineutrophil cytoplasmic antibody (ANCA) or anti-proteinase 3 ANCA positivity (+5); pulmonary nodules, mass, or cavitation on chest imaging (+2); granuloma or giant cells on biopsy (+2); inflammation or consolidation of the nasal/paranasal sinuses on imaging (+1); pauci-immune glomerulonephritis (+1); perinuclear ANCA or antimyeloperoxidase ANCA positivity (-1); and eosinophil count ≥1 × 109 /liter (-4). After excluding mimics of vasculitis, a patient with a diagnosis of small- or medium-vessel vasculitis could be classified as having GPA if the cumulative score was ≥5 points. When these criteria were tested in the validation data set, the sensitivity was 93% (95% confidence interval [95% CI] 87-96%) and the specificity was 94% (95% CI 89-97%). The 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology classification criteria for GPA demonstrate strong performance characteristics and are validated for use in research.

Mucormycosis in patients with COVID-19

Introduction: 2019 novel coronavirus (2019-nCoV) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first reported in Wuhan, in China, rapidly spread to other parts of the world forming a global pandemic. Secondary fungal or bacterial infections or coinfections are important challenges increasing the patients’ morbidity and mortality in COVID infection patients. The coronavirus disease-2019 (COVID-19) pandemic has led to increases in the cases of mucormycosis in India; rhino-orbito-cerebral mucormycosis is considered the most common type of mucormycosis, which is acquired by inhaling fungal spores in the paranasal sinuses. Objectives: The aims of this study were to assess the clinical and demographic profile of the patient with mucormycosis admitted to Government Medical College, Jalgaon and to identify the risk factors observed in the admitted patient with mucormycosis. Materials and Methods: The cross-sectional descriptive study was conducted among the patients admitted for the treatment of mucormycosis in Government Medical College and Hospital, Jalgaon, Maharashtra. A total of 91 patients admitted from April 15, 2021 to June 15, 2021 were enrolled as study participants. Result: More than half of the study participants were having complaints of swelling and pain over the cheek and face at the time of admission, whereas 20% were having pain in the nose, growth/swelling, and discharge from nose followed by toothache and loss of teeth in 13% of the study participants. More than 50% of patients were diabetic and 91% have a history of steroid use for the treatment of COVID-19. 57% of the study participants were having a history of diabetes. Conclusion: The physician should be more attentive for mucormycosis among the post-COVID-19 patients with diabetes patients and/or presenting with pain in the facial or orbital region or blackish or bloody nasal discharge.

A Rare Case of Pott's Puffy Tumor in an Elderly Man with a Background of Schizophrenia

Pott's puffy tumor (PPT) was first described by Sir Percival Pott in 1768. It is a life-threating complication of infectious sinusitis, which presents as a forehead swelling due to osteomyelitis of the frontal bone with an associated subperiosteal abscess (Hasan et al, 2019). It is not a true neoplasm; the name "tumor" refers to the swelling that occurs on the forehead as a result of the spread of infection. It is extremely rare in the post-antibiotic era and, when it does occur, tends to affect children and adolescents as the frontal sinus completes its development in preadolescents (Karaman et al, 2008). Very few cases of PPT have been documented in elderly individuals. The authors report the case of Pott's puffy tumor in a 71-year-old man with a background of chronic sinus disease, paranoid schizophrenia, and drug-induced Parkinsonism.An elderly man with a 12-day history of a worsening forehead abscess presented to the emergency department after being referred by his GP following 6 days of unsuccessful antibiotic therapy. On examination, a large, erythematous swelling was noted on his central forehead, measuring 15cm in diameter (Figure 1). The abscess was tender on palpation and fluctuant. There were no visual changes, exophthalmos, enophthalmos, or involvement of the periorbital area. The patient had a normal cranial nerve examination, except for slightly decreased sensation in the central forehead. His vital signs demonstrated tachycardia and, interestingly, he did not have a fever.The patient had a background of paranoid schizophrenia and was taking monthly injections of the typical antipsychotic flupentixol, as well as the anticholinergic procyclidine, for the drug-induced Parkinsonism. The patient lived in sheltered accommodation, smoked 10 cigarettes per day, and consumed cannabis. Recently, to note, the patient had a 2-month stay in a nearby mental health hospital.The patient was admitted, and the abscess was drained and irrigated with saline. Overnight, the abscess re-collected, and bloody nasal discharge was reported. This was re-drained the following morning, and examination after drainage suggested a possible involvement into the frontal sinus. The patient was listed for a CT scan, which demonstrated subcutaneous collection and acute frontal sinusitis complicated by erosion of the anterior wall of the frontal sinus in keeping with osteomyelitis (Figure 2). The CT scan also showed osteitis of the right frontal sinus and bilateral maxillary and sphenoid sinus walls consistent with chronic sinus disease. There was no evidence on CT of intracranial or orbital involvement.The patient was diagnosed with Pott's puffy tumor and referred to otolaryngology colleagues. The patient was commenced on IV piperacillin/tazobactam (tazocin) 4.5g tds and vancomycin 1g tds and listed for Functional Endoscopic Sinus Surgery (FESS).This case highlights the need for early recognition and prevention of benign infections that may subsequently become sinister or fatal. If not identified and managed swiftly, Pott's puffy tumor has a life-threatening sequela due to involvement into the frontal lobes of the brain. Hence, it is importance to have a high clinical suspicion for PPT in the face of medical and psychosocial risk factors. The authors emphasize the importance of a multidisciplinary team approach to managing patients with PPT, with valuable input from otolaryngology, neurosurgery, microbiology, and histopathology enhancing patient care.

Management of nasal myiasis and type 2 diabetes mellitus: A rare case and review article.

BackgroundNasal myiasis is a nasal infestation caused by house fly larvae (maggot). It's a rare condition with only a few reported cases and no treatment consensus.Case presentationA 54-year-old woman was admitted to the emergency unit with a complaint of larvae found in the left nasal cavity and bloody nasal discharge for 2 days. Anterior rhinoscopy found some living larvae in a narrowed left nasal cavity. Patient's management included larvae removal manually with forceps, nasal saline irrigation, a systemic broad-spectrum antibiotic, and insulin to controlled blood sugar.DiscussionRemoval of larvae in the nasal cavity using irrigation saline and systemic broad-spectrum antibiotics is effective in the absence of bone destruction.Conclusionmanual extraction combined with nasal saline irrigation and systemic broad-spectrum antibiotic was effective to manage nasal myiasis.

A Case Report of Multiple Intermittent Urticaria After Treatment of COVID-19 Infection

The authors report a case of a 32-year-old Thai woman with a COVID-19 infection that presented with urticaria and angioedema with a pityriasis rosea (PR)-like rash at a private hospital in Thailand. She presented at the hospital with bloody nasal discharge and diarrhea but without fever, myalgia, or any respiratory symptoms. She complained of angioedema and PR-like lesions on the third day of the treatment. Urticarial rash appeared intermittently for four weeks after all medications were discontinued, during which the patient had no fever, no respiratory symptoms, or any other symptoms. However, the RT-PCR results for COVID-19 RNA were positive during the time that the urticarial symptoms persisted. The COVID-19 RNA became negative on the fourth day after the last urticarial episode. Urticarial rash may be a clue that the inflammatory process is activated by COVID-19 virus after the treatment is completed. Keywords: Cutaneous; Pityriasis rosea; Angioedema; Urticaria; COVID-19

69-Year-Old Man With Nasal Congestion and Pre-Syncope

69-Year-Old Man With Nasal Congestion and Pre-Syncope

Conidiobolomycosis in Ovine in Southeast Bahia - Brazil

Background: Conidiobolomycosis is a highly lethal, granulomatous disease that primarily affects the respiratory system of sheep. The etiological agents are fungi of the genus Conidiobolus, including Conidiobolus coronatus, C. incongruus, and C. lamprageus. In Northeast Brazil, this disease is particularly important considering the significant impact sheep and goats have on the regional economy. The present report describes the occurrence of conidiobolomycosis in two sheep from the same property in the Itabuna-BA region that were referred to the Veterinary Hospital of the State University of Santa Cruz, Bahia, Brazil. Case: The primary complaint in both animals was bilateral bloody nasal discharge over a period of approximately 15 days and frequent coughing. On physical examination, the animals exhibited “goosebumps” and opaque hair, with a body score of 1 (scale, 1-5), mild dehydration (7%), apathy, frequent cough with putrid odor, bilateral serosanguinolent nasal discharge, craniofacial asymmetry, expiratory dyspnea, enlargement of the retropharyngeal lymph nodes, audible pulmonary rales, and pain on percussion of the pulmonary field. A therapeutic support protocol was established to stabilize the animals until the results of complete blood count, radiography, and microbiological evaluation of nasal content were available. Definitive diagnosis of disease was made by direct positive mycological examination, that revealed the presence of wide rarely septate hyphae, and isolation and cultivation of the fungus Conidiobolus sp., with microculture on slides and staining with lactophenol blue cotton. Due to disease diagnosis and the severity of injuries observed, the prognoses of both animals were considered to be unfavorable and led to euthanasia and necropsy. At necropsy, the most relevant findings were granulomatous rhinitis with ascending inflammatory processes to the meninges and adjacent structures, in addition to cranioventral areas of pulmonary consolidation with drainage of purulent exudate at the cut surface, suggestive of bronchopneumonia. Histopathology revealed intense pyogranulomatous inflammation associated with the presence of hyphae in negative images within the cytoplasm of multinucleated giant cells in the nasal cavity, lungs, meninges, and brain. Discussion: The association of necropsy findings, histopathological changes, and microbiological isolation of the fungus facilitated understanding of the changes observed in the respiratory system and other organs, and enabled correlation between the recorded lesions and clinical manifestations exhibited by the animals. Based on the lesions observed clinically and at necropsy, both cases were diagnosed with rhinopharyngeal conidiobolomycosis. The histopathological and macroscopic changes observed were similar to what are often described in severe cases of the disease. Considering the severity of the disease and its high lethality in these animals, conidiobolomycosis can lead to significant damage of the production chain; this was observed in the present property, where three animals in a herd of 20 died with signs of the disease, highlighting the importance of the disease, particularly in the Northeast region, where the largest flocks of sheep are found in Brazil. The implementation of prophylactic measures is particularly important considering the unfavorable prognosis and the absence of effective treatments.

Diseases caused by Pythium insidiosum in sheep and goats: a review.

Pythiosis is characterized most commonly by ulcerative dermatitis, mainly in the limbs of sheep and occasionally of goats. In sheep, Pythium insidiosum is also responsible for necrotizing rhinitis characterized by marked enlargement and deformity of the nasal region, severe respiratory difficulty, and bloody nasal discharge. A third form of pythiosis in sheep affects the digestive tract, involving ulceration of the esophagus, forestomachs, and abomasum. Pythiosis in sheep and goats has been reported only in Brazil where it occurs mainly in the semiarid region of the country, when animals congregate and stay for longer periods of time within or around water reservoirs. However, it has been reported as well in areas of humid environments, such as the Pantanal of Mato Grosso and in the Brazilian Cerrado. The diagnosis of the different presentations of pythiosis is based on gross and microscopic findings, coupled with detection of the agent by immunohistochemical, molecular, and/or culture-based methods.

EP22 A manifestation of severe sarcoid arthropathy in the distal interphalangeal joint

In 2011 a gentleman in his 50s presented with nasal blockage and bloody discharge. He was diagnosed with sarcoidosis and after 9 years of failed strategies to control his disease, he developed dactylitis. X-ray of the hands showed severe arthropathy in the distal interphalangeal joints. This case demonstrates an uncommon extrapulmonary manifestation of sarcoidosis. Although most of his follow up was with a respiratory clinic, his main symptoms were not due to interstitial lung disease, highlighting the importance of a multidisciplinary approach. To reduce the need for steroids, several DMARDs were tried illustrating that there are limited treatment options.

Nasal Cryptococcosis Caused by Cryptococcus gattii in Sheep in Bahia, Northeastern Brazil

Background: Cryptococcosis is a potentially fatal systemic mycosis that can affect several animal species. The disease is caused by the yeast species Cryptococcus neoformans and C. gattii and is usually associated with immunosuppressive diseases or debilitating factors. In Brazil, cryptococcosis in ruminants has been described in several states, but there have been only two instances of infection in sheep. Until the present, cryptococcosis caused by C. gattii has only been reported in goats. The objective of this study was to describe, for the first time, a case of nasal cryptococcosis caused by C. gattiiin a sheep in the state of Bahia.Case: The disease affected a 4-year-old Santa Inês sheep, created in extensive system in the municipality of Ribeira do Pombal, Bahia, Brazil. The animal presented weight loss, with an asymmetric volume increase in the right nasal cavity, accompanied by dyspnea and bloody nasal discharge. Samples of the tumor mass were collected for cytological analysis of yeast structures compatible with Cryptococcus spp. After cytological diagnosis, the sheep was sent to the Livestock Development Center of the Federal University of Bahia. On physical examination, there was a large and firm irregular mass, strongly adhering to the right nasal cavity and causing facial asymmetry. Surgical removal was attempted, but a marked infiltrative character of the lesion was observed, with extensive tissue destruction. Owing to the unfavorable prognosis, euthanasia was carried out followed by necropsy, in which a large irregular mass was observed that almost completely obliterated the right nasal cavity. Resorption of the right nasal bone and the dorsal and middle nasal turbinates was also observed. Fragments of the nasal lesion were collected, fixed in 10% formalin, routinely processed for histopathology, and stained with hematoxylin and eosin (HE) and Mayer's mucicarmine. Samples of this lesion were sent for molecular characterization of the etiologic agent by polymerase chain reaction (PCR). The histopathological evaluation showed hundreds of generally colorless rounded yeasts cells composed of a clear halo, surrounding a slightly basophilic structure, giving the tissue a vacuolated aspect, known as a “soap bubble lesion” There was also intense inflammatory infiltration and extensive areas of necrosis and hemorrhage, which allowed the morphological diagnosis of diffuse granulomatous rhinitis marked with intralesional yeasts compatible with Cryptococcus spp. Additionally, PCR was positive for C. gattii.Discussion: A case of nasal cryptococcosis caused by C. gattii in sheep in the state of Bahia is described for the first time, diagnosed using clinical-epidemiological, cytological, anatomopathological, and molecular data. Airborne infection occurs by inhaling encapsulated spores present in organic matter, such as decomposing vegetables and bird and bat excreta as observed on the farm where the outbreak occurred. It is important to highlight that sheep and goats affected by cryptococcosis can contaminate the environment, and it is prudent to consider animals with the disease as a risk to public health and eliminate them from the herd, given the costs of the few therapeutic options available on the market. It should be noted that in cases of tumor lesions, which are common in cryptococcosis, cytological examination should be recommended, mainly for screening and distinguishing neoplastic and inflammatory lesions. However, anatomopathological and molecular evaluations are essential for the differential diagnosis of other mycotic rhinitis, in particular, conidiobolomycosis and nasal pythiosis.

Rhino-maxillary aspergillosis in an immunocompetent patient. Case report.

Introduction: Aspergillosis is the second most frequent opportunistic fungal infection of the paranasal sinuses. It primarily affects the maxillary sinus and occurs mainly in immunocompromised individuals. Infection is caused by inhalation of spores or by an oro-sinusal communication. Aspergillosis is classified into an invasive and non-invasive form or Aspergilloma, which usually affects immunocompetent patients. Violaceous lesions, ulcers, necrosis and tissue destruction can be manifested clinically. Patients may experience pain, paresthesias, increases in the volume of purulent or bloody nasal discharge and congestion. Case report: A 62-year-old female patient, immunocompetent, with a condition evolving for about six years. Condition began after a dental extraction, and consisted of absence of scarring and recurrent episodes of symptomatology suggestive of maxillary sinusitis with poor response to antibiotics. The patient was referred to the maxillofacial care unit, presenting an increase of volume in the right genial region, pain and paraesthesia of infraorbital region. The CT scan showed the presence of a radiopaque foreign body in the right maxillary sinus. A surgical procedure was carried out using the Caldwell-Luc technique and biopsy; the case was diagnosed with Aspergillosis. The patient was treated without antifungal therapy because she had a good immune status. Conclusion: Aspergilloma is the most common form of Aspergillosis in immunocompetent individuals. It is usually diagnosed late, as its clinical picture is similar to bacterial sinusitis. In most cases, patients respond well to surgical treatment, and systemic antifungal therapy is not necessary.

Different types of intranasal steroids for chronic rhinosinusitis.

This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in the sinonasal mucosa in order to improve patient symptoms. To assess the effects of different types of intranasal steroids in people with chronic rhinosinusitis. The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015. Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing first-generation intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) with second-generation intranasal corticosteroids (e.g. ciclesonide, fluticasone furoate, fluticasone propionate, mometasone furoate, betamethasone sodium phosphate), or sprays versus drops, or low-dose versus high-dose intranasal corticosteroids. We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis (nosebleed). Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse event of local irritation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. We included nine RCTs (911 participants), including four different comparisons. None of the studies evaluated our first primary outcome measure, disease-specific HRQL. Fluticasone propionate versus beclomethasone dipropionate We identified two small studies (56 participants with polyps) that evaluated disease severity and looked at the primary adverse effect: epistaxis , but no other outcomes. We cannot report any numerical data but the study authors reported no difference between the two steroids. The evidence was of very low quality. Fluticasone propionate versus mometasone furoate We identified only one study (100 participants with polyps) that evaluated disease severity (nasal symptoms scores), which reported no difference (no numerical data available). The evidence was of very low quality. High-dose versus low-dose steroidsWe included five studies (663 participants with nasal polyps), three using mometasone furoate (400 µg versus 200 µg in adults and older children, 200 µg versus 100 µg in younger children) and two using fluticasone propionate drops (800 µg versus 400 µg). We found low quality evidence relating to disease severity and nasal polyps size, with results from the high-dose and low-dose groups being similar. Although all studies reported more improvement in polyp score in the high-dose group, the significance of this is unclear due to the small size of the improvements.The primary adverse effect, epistaxis , was more common when higher doses were used (risk ratio (RR) 2.06, 95% confidence interval (CI) 1.20 to 3.54, 637 participants, moderate quality evidence). Most of the studies that contributed data to this outcome used a broad definition of epistaxis, which ranged from frank bleeding to bloody nasal discharge to flecks of blood in the mucus. Aqueous nasal spray versus aerosol spray We identified only one poorly reported study (unclear number of participants for comparison of interest, 91 between three treatment arms), in which there were significant baseline differences between the participants in the two groups. We were unable to draw meaningful conclusions from the data. We found insufficient evidence to suggest that one type of intranasal steroid is more effective than another in patients with chronic rhinosinusitis, nor that the effectiveness of a spray differs from an aerosol. We identified no studies that compared drops with spray.It is unclear if higher doses result in better symptom improvements (low quality evidence), but there was moderate quality evidence of an increased risk of epistaxis as an adverse effect of treatment when higher doses were used. This included all levels of severity of epistaxis and it is likely that the proportion of events that required patients to discontinue usage is low due to the low numbers of withdrawals attributed to it. If epistaxis is limited to streaks of blood in the mucus it may be tolerated by the patient and it may be safe to continue treatment. However, it may be a factor that affects compliance.There is insufficient evidence to suggest that the different types of corticosteroid molecule or spray versus aerosol have different effects. Lower doses have similar effectiveness but fewer side effects.Clearly more research in this area is needed, with specific attention given to trial design, disease-specific health-related quality of life outcomes and evaluation of longer-term outcomes and adverse effects.

Photo Quiz: A 54-Year-Old Male with Acute Myelogenous Leukemia Presenting with Right Periorbital Swelling and Diplopia

A 54-year-old male from South Dakota with recently diagnosed acute myelogenous leukemia (AML) presented with right-sided facial pain associated with right periorbital swelling, diplopia, and bloody nasal discharge. He had received standard induction chemotherapy with cytarabine and idarubicin during

Button Battery Injuries in the Pediatric Aerodigestive Tract

Children with a button battery impaction present with nonspecific symptoms that may account for a delay in medical care. We conducted a retrospective study of the clinical presentation, management, and complications associated with button battery ingestion in the pediatric aerodigestive tract and to evaluate the associated long-term morbidity. We reviewed the medical records of 23 patients who were treated for button battery impaction at our tertiary care children's hospital from Jan. 1, 2000, through July 31, 2013. This population was made up of 14 boys and 9 girls, aged 7 days to 12 years (mean: 4 yr). Patients were divided into three groups based on the site of impaction; there were 9 impactions in the esophagus and 7 each in the nasal cavity and stomach. We compiled information on the type and size of each battery, the duration of the impaction, presenting symptoms, treatment, and outcomes. The mean duration of battery impaction was 40.6, 30.7, and 21.0 hours in the esophagus, nasal cavity, and stomach, respectively. We were able to identify the specific type of battery in 13 cases; 11 of these cases (85%) involved a 3-V 20-mm lithium ion battery, including all cases of esophageal impaction in which the type of battery was identified. The most common presenting signs and symptoms were vomiting (n = 7 [30%]), difficulty feeding (n = 5 [22%]), cough (n = 5), and bloody nasal discharge (n = 5); none of the presenting signs and symptoms predicted the severity of the injury or the outcome. The median length of hospital stay was far greater in the esophageal group (12 days) than in the nasal and stomach groups (1 day each; p = 0.006). Battery impaction in the esophagus for more than 15 hours was associated with a significantly longer postoperative hospital stay than impaction for less than 15 hours (p = 0.04). Esophageal complications included strictures (n = 5), perforation (n = 3), and tracheoesophageal fistula formation (n = 2). Clinicians should consider battery impaction in the upper aerodigestive tract as an emergency that can lead to significant long-term morbidity, and therefore immediate surgical intervention is required.

Progressive left-sided facial swelling and proptosis.

Case Presentation A previously healthy 87-year-old African-American man presented to an urgent care facility with left nasal congestion. He reported a twoweek history of nosebleeds, low-grade fever, night sweats and general malaise. He was treated with intravenous ceftriaxone and prescribed oral levofloxacin for suspected acute bacterial sinusitis. Due to worsening symptoms, left eye swelling and continued bloody nasal discharge, he went to a local emergency department and was admitted to the hospital and treated with intravenous ampicillin plus sulbactam for community-acquired acute bacterial rhinosinusitis; however, despite empirical therapy, his facial swelling progressed to involve the periorbital region. He developed left facial numbness, proptosis and decreased vision in the left eye (Figure 1). On examination, he was afebrile and his heart rate was 82 beats/min, respiratory rate was 23 breaths/min and blood pressure was 130/86 mmHg. The patient was alert and cooperative. He had a small amount of bloody nasal discharge and left-sided facial swelling with tenderness noted in the maxillary area. Additional findings included left eye swelling without erythema that limited eye opening and examination. There was no pharyngeal erythema or oral lesions. He had no cervical adenopathy or organomegaly. There were no cutaneous or musculoskeletal findings. His respiratory, cardiovascular, abdominal and neurological examination were unremarkable. He had a white blood cell count of 170×109/L with 60% neutrophils, 8% bands, 16% monocytes, 14% metamyelocytes and 2% lymphocytes. He was anemic and thrombocytopenic; his hemoglobin level was 74 g/L and platelet count was 13×109/L. His prothrombin time was 17.9 s, partial thromboplastin time 34.5 s and international normalized ratio was 1.44. His plasma chemistry, including liver function tests and blood glucose measurements, were normal. Magnetic resonance imaging of the brain with contrast demonstrated the presence of extensive left-sided sinusitis involving the frontal, sphenoid, ethmoid and maxillary sinuses, with intraorbital extension of infection to the left medial superior orbit. As part of management, debridement and left inferior turbinate biopsy was performed by ear, nose and throat surgery. Based on the patient’s history, physical examination and clinical findings, what is the most likely diagnosis?

Rhino-orbito-cerebral mucormycosis in a child with diabetic ketoacidosis.

Sir, Rhino-orbito-cerebral mucormycosis is an unusual complication of diabetic ketoacidosis (DKA). Most of them have been fatal. High index of suspicion is critical for diagnosis and early treatment. A 9-year-old, female child presented with fever, abdominal pain, and vomiting for 2 days. Examination revealed acidotic breathing and multiple furuncles over the face. She had hyperglycemia of 485 mg/dl, ketonuria, wide anion gap metabolic acidosis (pH 6.8) and polymorphonuclear leucocytosis. She was diagnosed as Type 1 diabetes with DKA and treated according to the DKA management protocol of the unit. In view of persistent altered sensorium anti-edema measures were initiated. At 48 h of admission, she had a dark colored bloody nasal discharge. Injection amphotericin B was started empirically for suspected mucormycosis. At 72 h, the child developed ophthalmoplegia of the right eye. A black necrotic palatal lesion was noted at 96 h [Figure 1]. Computed tomography (CT) brain was normal. CT paranasal sinuses showed right maxillary sinusitis. Nasal endoscopy revealed black necrotic eschar over the right middle and inferior turbinates, floor and lateral wall of nasal cavity. Despite surgical debridement child worsened with right facial palsy and left hemiparesis. Repeat CT brain revealed massive infarct involving right frontal, temporal and parietal regions. The child expired on day 9. Figure 1 Black necrotic eschar in palate Histopathology of the necrotic lesion revealed broad, aseptate hyphae, branching at right angles with vascular invasion. Culture on saboraud dextrose agar medium grew black colonies typical of Rhizopus. On lactophenol cotton blue mount presence of sporangium and rhizoids typical of Rhizopus was seen. Postmortem cerebral spinal fluid was unusually orange-red colored with no cells, with 1250 mg% proteins and 35 mg% sugar. Hemoglobin A1c was high (12.6%). Mucormycosis is an acute, frequently fatal, fungal disease in immunocompromised children due to Rhizopus[1] followed by Mucor. Risk factors include DKA, prolonged neutropenia, malignancy, chronic corticosteroid therapy and deferoxamine therapy. Rhinocerebral (most common in DKA),[2] pulmonary, cutaneous, gastrointestinal, and disseminated involvement can be seen. In DKA, the chemotactic activity of neutrophils and their ability to produce reactive oxygen species is diminished. Acidosis disrupts the transferrin binding to iron,[3] releasing free iron favoring Rhizopus growth. As the advanced glycosylation end products increases the transendothelial migration of neutrophils decreases. Following inhalation, the disease begins with facial pain and numbness followed by sinusitis and dark bloody nasal discharge. In this child, nasal discharge was the first sign. The infected tissue appears normal initially then become erythematous, violaceous and finally turns black due to thrombosis and tissue infarction.[4] Rapid progression of the disease occurs in hours to days. Direct microscopic examination of the specimen and culture are diagnostic. Management includes reversal of the risk factor, surgical debridement along with antifungal therapy. Amphotericin B (polyene) is the drug of choice given over few weeks. Amphotericin B liposomal complex, echinocandins with polyenes, posaconazole and deferasirox can also be used. Clinical suspicion warrants treatment without awaiting confirmation. Mortality is more than 40% with cerebral involvement. It is less than 10% without cerebral involvement.[2] Poor prognostic factors are delayed diagnosis, inadequate surgical debridement, spread beyond sinonasal cavity, and cerebral involvement.

Diphtheria in a 7-year-old child in north-eastern Nigeria – management in a resource-poor setting

We report a case of a 7-year-old unimmunized child who presented with a 2 week history of nasal quality speech, hoarseness of the voice, regurgitation of feeds, and unstable gait. He had a previous history of fever, severe sore throat and bloody nasal discharge. A throat swab was negative for Corynebacterium diphtheria; however, he had received antibiotics at a primary care clinic prior to presentation. A clinical diagnosis of diphtheria with neurologic complication was made and the child was started on oral erythromycin, nasogastric tube feeding and daily physiotherapy, following which he improved. We did not prescribe diphtheria anti-toxin because of its unavailability.

Nasopharyngeal carcinoma in children and adolescents in an endemic area: A report of 185 cases

BackgroundThis study aimed to demonstrate the clinical and therapeutic features of nasopharyngeal carcinoma (NPC) in children and adolescents in Southern China, an endemic area. Patients and methodsA total of 185 newly diagnosed NPC patients younger than 21 years old in the Sun Yat-sen University Cancer Center from 1993 to 2011 were retrospectively analyzed. Overall survival (OS) rate estimates and Kaplan–Meier survival curves were calculated. Cox proportional hazard ratios (HRs) were used to identify independent prognostic factors for survival. Chi-square test was used to compare the incidence of sequelae and the stage distribution between different subgroups. ResultsMost patients were male (71.4%). The main presenting symptoms were neck mass (44.9%), tinnitus/hearing loss (36.2%), bloody nasal discharge (22.7%), headache (22.2%), and nasal obstruction (20.0%). Stage I, II, III, and IV patients accounted for 1.1%, 8.1%, 43.8%, and 47.0%, respectively, of the total number of patients included in the study. All patients were treated by radiotherapy: 39Gy–84Gy to primary tumors (median, 68Gy) and 36Gy–74Gy to cervical lymph nodes (median, 60Gy); 84.3% of the patients were treated by chemotherapy either. The complete response rate was 94.1%. The 5-, 10-, and 15-year survival rates were 78%±4%, 70%±5%, and 66%±6%, respectively. Tumor node metastasis (TNM) stage was the statistically significant predictor of distal metastasis and OS. Distal metastasis was the major pattern of treatment failure. The main long-term complications of therapy were xerostomia (47.0%), hearing loss (28.1%), neck fibrosis (24.3%), trismus (12.4%), glossolalia (7.0%), and radiation encephalopathy (5.4%). The incidences of these morbidities were significantly higher in the high radiation dose (more than the median) group than in the low radiation dose group (less than or equal to the median), while no differences in survival were observed. ConclusionsIn spite of the majority of patients diagnosed at the advanced stage, children and adolescents with NPC had excellent survival except metastatic disease. The TNM stage was the most relevant prognostic factor. A higher radiation dose (>68Gy) could not improve survival but could increase long-term morbidities.

Outbreak of infectious laryngotracheitis in large multi-age egg layer chicken flocks in Minas Gerais, Brazil

A recent (November 2010) outbreak of infectious laryngotracheitis (ILT) in a multi-age laying hen facility in Minas Gerais state, Brazil, is described. Previous ILT outbreak in laying hens was only notified in São Paulo state, Brazil, in 2002. In the outbreak described here, the affected population was approximately eight million hens, with flock sizes ranging from 100,000 to 2,900,000 chickens. The average mortality ranged from 1 to 6%, and morbidity was around 90% (most of the twenty seven farms of the area were positive for ILT virus). Three multi-age laying farms from one company were selected for this report. Clinical signs included prostration, dyspnea, conjunctivitis, occasional swelling of the paranasal sinuses and bloody mucous nasal discharge. Severely affected chickens presented with dyspnea, gasping and became cyanotic before death. At necropsy, these chickens had fibrinous exudate blocking the larynx and the lumen of cranial part of the trachea. In addition, conjunctivitis with intense hyperemia, edema and sinuses with caseous exudate were present. On histopathology, there were marked necrosis and desquamation of respiratory ephitelium and conjunctiva with numerous syncytial cells formation and fibrinous exudate. Moderate to marked non suppurative (especially lymphocytes and plasma cells) infiltration in the lamina propria also was observed. Sixteen out of 20 examined chickens, eosinophilic intranuclear inclusion bodies were observed in the syncytial cells. The DNA extracted from larynx and trachea produced positive PCR results for ILT virus (ILTV) DNA using formalin-fixed, paraffin embedded (FFPE) samples. Amplicons from a small region of ICP4 gene were submitted to sequencing and showed 100% identity with ILTV EU104910.1 (USA strain), 99% with ILTV JN596963.1 (Australian strain) and 91% with ILTV JN580316.1 (Gallid herpesvirus 1 CEO vaccine strain) and JN580315.1 (Gallid herpesvirus 1 TCO vaccine strain).

Rhino-orbitocerebral mucormycosis in a patient with idiopathic crescentic glomerulonephritis

Mucormycosis, caused by mucorales, is an acute, rapidly progressive infection associated with high mortality. Rhino-orbitocerebral infection is the most common variant and is generally seen in association with immune deficiency syndromes. Prompt medical treatment of this infection and debridement decreases the mortality rate. We describe a 47-year-old man with crescentic glomerulonephritis on maintenance prednisolone therapy. He had earlier received steroid and cyclophosphamide pulse therapies. Renal functions improved following immunosuppressive treatment. In the third month of maintenance therapy, he presented to us with left-sided facial swelling and bloody nasal discharge. He had high blood sugar and acidic blood pH (ketoacidosis), probably due to steroid therapy. Magnetic resonance imaging of the head and sinuses showed inflammation and mass in the ethmoid sinus and nose with partial septal destruction, proptosis, global destruction of the left eye, brain infarction and carotid artery obliteration. Endoscopic biopsy of the sinuses revealed severe tissue necrosis. Samples of nasal discharge and biopsy tissue showed aseptate hyphae on light microscopy and culture, compatible with Rhizopus. The patient was treated with amphotericin B and multiple wound debridements along with ethmoidectomy and enucleation of the left eye. He was discharged in good general condition but with mild right hemiparesis. On follow-up examination at one year, there were no signs of fungal infection or renal dysfunction.