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|Year : 1977 | Volume
| Issue : 3 | Page : 140-142
Subcutaneous facial aspergillosis
M Madhavan, AL Aurora, KR Gupta, RN Sibal
Department of Pathology, E.N.T. Diseases and Surgery Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry-6., India
Department of Pathology, E.N.T. Diseases and Surgery Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry-6.
Source of Support: None, Conflict of Interest: None
Two cases of subcutaneous facial aspergillosis are being reported. As the overlying skin was healthy, the mode of localisation of fungus remains unclear; because of peculiarity of clinical presentation the diagnosis was brought out only by histology. This mode of presentation has to be kept in mind in the predominantly agricultural communities in India.
|How to cite this article:|
Madhavan M, Aurora A L, Gupta K R, Sibal R N. Subcutaneous facial aspergillosis. J Postgrad Med 1977;23:140-2
Aspergillosis is a well-known opportunistic fungal infection occurring in cases of leukaemia, immunosuppressive therapy, prolonged steriod and antibiotic therapy and in recent years is seen commonly in renal transplant recipients. , The lungs are the most frequently involved viscera, followed by gastrointestinal tract, kidneys and central nervous system: No site appears to be exempted from the disease process especially in disseminated aspergillosis. Primary involvement of lungs is on record  where the lesion resembles lobar pneumonia or a chronic lung abscess. Primary aspergillosis of the paranasal sinuses  and primary mycotic intrasellar abscess leading to superficial meningo encephalitis  have also been observed. Here we report subcutaneous aspergillosis involving the face, with uninvolved overlying skin which so far appears to be not recorded elsewhere.
| :: Case report|| |
Case 1: A 45 year old male came to the hospital for swelling over the right malar region, of 5 months duration. He complained of loss of sensation over the right side of the face with epiphora since the last 5 months. The swelling was of insidious onset. There was no history of blood stained nasal discharge, nasal block, blurring of vision or diplopia. There was no history of trauma to the region. The swelling extended medially to the lateral nasal wall and laterally was seen behind the zygomatic process of the maxilla. The floor of the orbit appeared to be free and the skin over the swelling was uninvolved. Examination of the nose showed bulging of the lateral nasal wall into the nasal cavity with fullness of right half of the hard palate. The swelling was firm to hard in consistency. Maxillary antrum appeared to be free. The loss of sensation referred to by the patient was not objectively observed and there was no evidence of involvement of central nervous system. The patient was afebrile throughout the period of his illness and during his hospital stay. The submandibular and submental lymphnodes on the right side were enlarged and hard. A diagnosis of ?Haematoma ?Carcinoma arising from the maxillary antrum was made and a Caldwell-Luc operation was done. At operation the swelling was found to be limited to the malar region and the anterolateral wall of the maxillary antrum was free and intact. The mass was removed enmasse with a provisional diagnosis of neurofibroma arising from the infra-orbital nerve. Histology revealed granulomatous reaction with scattered areas of caseous necrosis, bordered by epithelioid cells and a large number of foreign body type of giant cells See [Figure 1] on page 142a. Structures suggestive of fungal hyphae could be observed on closer examination in the Haematoxylin-Eosin stained sections. These hyphae were seen scattered in the granulomas or contained within some of the giant cells. PAS and Methanamine silver stains confirmed the presence of fungal hyphae See [Figure 2] on page 142a, the morphology of which conformed to that of Aspergillus genus. Histology also confirmed the clinical impression, that the antral mucosa was free of the infection and was normal. This excluded the possibility that the infection was secondary to antral involvement. Culture study was not done as the wound had healed well without any purulent discharge on the 5th day of operation, when the biopsy diagnosis was known. The patient left the hospital, symptom free, 20 clays after the admission.
Case II: S, a 50 year old male came with a swelling over the right side of the face since the last one year. It was of insidious onset and had gradually increased to the present size. There was no pressure effect on the eye or the nose. On examination the swelling was oval in shape, 6 X 4 cms, in size, situated over the right side of the face, medially 2 cms lateral to the ala of the nose and laterally about 1.5 cms above the angle of the mandible. It was well away from the maxillary antrum and was not connected to nasal or oral cavity. It was soft in consistency with no pulsations and had a uniform smooth surface. The overlying skin was free. The patient was afebrile and was otherwise healthy. Excision of the swelling was done with a diagnosis of ?Chronic abscess, ?infected sebaceous cyst. The excised mass, on gross examination, was a thickwalled cystic swelling measuring 4.5 cms in diameter which, on sectioning, contained necrotic material, bordered by yellowish inner lining. Sections revealed the lining of the cavity to be consisting of epithelioid cells, with many foreign body type of giant cells. No mucosal lining of any type was discernible. Careful examination revealed fungal hyphae scattered throughout the granulomatous zone, some lying inside the giant cells. PAS and Methanamine silver stains brought out the hyphae very clearly See [Figure 3] on page 142a and the morphological characteristics conformed to that of Aspergillus genus. As there was no epithelial lining limiting the cavity it was not considered to be sebaceous cyst secondarily infected by the fungus. As the swelling was situated inferior and lateral to the maxillary antrum, no connection with the paranasal sinuses was suspected and X-ray of the paranasal sinuses was not done. Culture studies were not done as the patient was discharged soon after his operation, before the biopsy report was known.
| :: Comments|| |
It is obvious that these two cases were not conforming to the clinical spectrum of circumstances where aspergillosis is commonly encountered. But for the localised facial swelling both patients were asymptomatic and routine laboratory investigations did not reveal any haematological or metabolic abnormality. In both - cases the overlying skin was stretched but intact without any surface ulceration. The peculiarity of the presentations and the site involved obviously led to difficulties in diagnosis. Both the patients belonged to agricultural community. It is likely that some minor injury to the facial skin in the nature of an abrasion might have allowed the fungus to gain entry into the subcutaneous plane, but as there was no noticeable abnormality of the surface skin, this possibility remains remote. Perhaps in the predominantly agricultural communities of India, subcutaneous aspergillosis has to be kept in mind in cases of subcutaneous abscess.
| :: Acknowledgement|| |
We wish to thank Dr. D. B. Bisht, Principal, JIPMER, for allowing us to publish this case report.
| :: References|| |
|1.||Fraser, R. G. and Pare, J. A. P.: Diagnosis of Disease of the chest. 1st edition, W. B. Saunders, Philadelphia, P-665, 1970. |
|2.||Goldhammer, Y., Smith, L, and Yates, B. M.: Mycotic intraseller abscess. Amer. J. Ophthal., 78: 478-484, 1974. |
|3.||Gruhn, J. G. and Sanson, J.: Mycotic infections in leukaemic patients at autopsy. Cancer, 16: 61-73, 1963. |
|4.||Young, R. C., Bannett, J. E., Vogel, C. L., Carbone, P. P. and De Vita, V. T.: Aspergillosis: The spectrum of the disease in 98 patients. Medicine (Baltimore), 49: 147-173, 1970. |
|5.||Welter, W. A., Joseph, D. J. and Hora, J. F.: Deep mycotic involvement of the right maxillary and ethmoid sinuses, the orbit and adjacent structures. Laryngoscope, 70: 999-1016, 1960. |
[Figure 1], [Figure 2], [Figure 3]