Case 3 -

A Multitude of Mistakes or the Case of the Discarded Fungus Nancy Cornish Nebraska Methodist Health System Omaha, NE

Click on each slide thumbnail image for an enlarged view

Click here to download and print the PowerPoint presentation (PDF file - 520KB) Clinical History 73 yr. old woman with chronic left maxillary sinus pain. CT scan of the sinuses showed complete opacification of the left maxillary sinus with bony erosion in a portion of the medial wall of the sinus. Chronic infection or malignancy? Case 3 - Figure 1 - Septate hyphae and conidia. H&E stain. 40X magnification Case 3 - Figure 2 - Another structure present. H&E stain. 40X magnification Case 3 - Figure 3 - Additional spores or spore-like structures 40X magnification Surgical exploration revealed “obvious green and black fungal debris oozing from the maxillary ostium”. The surgeon sent a swab of the left maxillary curettage specimen for bacterial culture and the specimen to surgical pathology for histological exam. A routine bacterial culture was set up and grew two types of Coagulase-negative Staph and rare Enterobacter cloacae. The direct gram stain showed some cellular debris and a few gram positive cocci (no segmented WBC seen). The technologist questioned me whether she should do susceptibilities. Because the swab was a large tipped swab and not a mini-tip, she thought this was not a true sinus specimen but a nasal specimen and as such, not worthy of work up. She reasoned that a large tip swab would not be able to go through the maxillary ostiaand would be contaminated by nasal secretions. Investigation of the case revealed that the surgical pathology report had been signed out as “chronic sinusitis, NOS” but that the operative report clearly stated that fungus was present, due to the discrepancy the surgical slide was reviewed. Brown pigmented septate hyphae and conidia were seen. The surgeon was called and he stated that he didn’t think he needed a fungal culture because he already knew it was a fungus. If he needed to treat he would use Amphotericin B instillations. He was educated to the fact that some fungi are intrinsically resistant to Amphotericin and other antifungal agents. Culture is needed for identification. A Supplemental pathology report was issued: Review of the slides reveals brown pigmented septatehyphaeand conidia consistent with a dematiaceous fungus. Definitive invasion of tissue is not seen. A gram stain shows gram positive cocci primarily in the areas of necrotic debris. They appear to be colonizing the debris based on location and a lack of acute inflammatory cells associated with the bacterial organisms. See fungal culture report for definitive ID of fungus present. The surgeon told us he had, in fact sent us a small piece of tissue which he had jammed down into the culturette tube with the swab. The culturette tube was retrieved and cut open. A small piece of tissue was found in the packing material in the bottom of the tube This tissue was set up for fungal culture. The culture grew Scedosporium apiospermum This fungus is the asexual state of Pseudallescheria boydii Often resistant to Amphotericin B and Flucytosine but susceptible to the azoles (including Voriconazole) Comment placed on fungal culture report: These fungi are often resistant to Amphotericin B. References Pathology of Hyalohyphomycosiscaused by Scedosporiumapiospermum(Pseudallscheriaboydii) An Emerging Mycosis; Tadroset. al. Human Pathology: Vol29, No. 11 (Nov 1998) A Guide to Specimen Management in Clinical Microbiology; J. Michael Miller-2ndedition, ASM Press, 1999 Fungal Infections of the Nose and Paranasal Sinuses (Parts I andII); Lawson, W. et. al. , OtolaryngologicClinics of North America, Vol. 26; 6: Dec. 1993, pages 1007-1035 and 1039-1068 Fungal sinusitis; DeShazoet. al. NEJM, Vol337, pg. 254-259, July 24,1997 Article and posters can be downloaded from following College of American Pathologist’s “CAP Today”website: http://www.cap.org/apps/docs/cap_today/feature_stories/0804Swabs.html.