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Polymorphic cutaneous rhinosporidiosis

European Journal of Dermatology. Volume 16, Number 2, 190-2, March-April 2006, Clinical report

Summary

Author(s) : Ashok Ghorpade , Department of Dermatology, Venereology and Leprosy, JLN Hospital & Research Center, Bhilai Steel Plant, Bhilai, Chattisgarh state, India.

Summary : Rhinosporidiosis is a chronic granulomatous condition caused by Rhinosporidium seeberi primarily affecting the mucosa of the nose, eyes and sinuses. The patients usually present with nasal symptoms and skin involvement is uncommon [1-3]. Here, a patient with nasal rhinosporidiosis having two different morphological types of cutaneous lesions of rhinosporidiosis, coexisting at the same time and at the same site, is reported. The diagnosis was confirmed by FNAC (Fine Needle Aspiration Cytology) and skin biopsy from the skin lesions. To the best of my knowledge, such an unusual occurrence has not been reported earlier in literature.

Keywords : cutaneous rhinosporidiosis, polymorphic lesions, Rhinosporidium seeberi

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ARTICLE

Auteur(s) : Ashok Ghorpade

Department of Dermatology, Venereology and Leprosy, JLN Hospital & Research Center, Bhilai Steel Plant, Bhilai, Chattisgarh state, India

accepté le 17 Août 2005

Rhinosporiodiosis is endemic in Sri Lanka and South India, though it has been described from several parts of the world including Africa, South America, Italy, Cuba, and the United States. In India, most of the reported cases are from the southern states of Kerala and Tamil Nadu. A large number of cases of nasal rhinosporidiosis have also been previously reported from our state [4]. Many aspects of this disease are not clearly understood, but prolonged exposure to stagnant water and repeated trauma are probably the two important factors for acquisition of the infection. It is more common in males, probably due to their increased risk of exposure, and is mostly seen during second to fourth decade [4-7]. The possibility of different types of cutaneous lesions of this condition, occurring at the same time in one patient should be kept in mind [8-10].

Case report

A 52-year-old male, from a village adjoining Bhilai presented with the history of asymptomatic skin lesions on his left leg and right forearm, of 5 months duration. The patient had been treated for nasal rhinosporidiosis privately with dapsone tablets for the previous 8 months. He gave a history of bathing with cattle in the common village pond since early childhood, since tap water was not available there. His wife and two children were normal.

Cutaneous examination showed a skin colored, ill defined, soft, non tender, subcutaneous mound-like swelling about 5 cm. in diameter, located on the anterior aspect of his left leg near the knee joint. The top of the mound was capped by a button like, dirty white, flat, firm, circular, warty plug-like lesion, about 7 mm in diameter (( figure 1 )). There was an ill defined, huge, firm, skin colored, non-tender, subcutaneous swelling on his right forearm about 18 cm × 5 cm in size (( figure 2 )). Nasal examination showed a bright red, granulomatous, polypoidal lesion in the left nares about 0.5 cm in diameter. There were no other skin lesions or significant systemic findings. Routine hematology and X-ray of the limbs were normal. FNAC from both the subcutaneous lesions revealed multiple sporangia packed with endospores (( figure 3 )). The skin biopsy from the verrucous lesion showed epidermal changes in the form of hyperkeratosis, irregular acanthosis and multiple sporangia with endospores with a sparse chronic inflammatory infiltrate. Surgery with electrodessication of the base was carried out for the nasal lesion but the patient did not agree for operative removal of the skin lesions and was lost to follow-up.

Discussion

Rhinosporidiosis usually presents in the nasopharynx as a friable, pedunculated or sessile vascular polyp(s), studded with tiny whitish dots. Eye involvement can be seen in about 15% patients, mostly in the conjunctiva [11]. Occasionally, it can involve the palate, uvula, larynx, epiglottis, trachea, bronchus, maxillary antrum, vulva, vagina, penis, rectum or the skin [12]. Isolated conjunctival, lacrimal sac [11, 13, 14], and parotid duct involvement [15] have also been reported.

A large collection of cases of oculosporidiosis [11] and a case of urethral rhinosporidiosis [16], were published from Nepal. Four migrant workers from South India and Bangladesh were found to have nasal rhinosporidiosis, while working in Singapore [17].

The exact mode of disease transmission is not clear. The infection may be acquired through contaminated dust, water, infected clothing or fingers. Bathing in ponds and muddy waters is one of the risk factors noted by many workers [1-3, 9, 12, 17]. Common pond bathing with animals has also been blamed for its acquisition [1-3, 12]. Paddy cultivators seem to be more prone to this infection [10, 16, 17].

Cutaneous rhinosporidiosis may occur as satellite lesion from nasal involvement, disseminated lesions with or without nasal lesions or as primary cutaneous involvement. Skin lesions usually begin as friable papillomas or as warty papules and nodules with whitish spots. The smaller skin lesions have to be differentiated from common warts, tuberculosis verrucosa cutis, granuloma pyogenicum and in case of genital lesions, from venereal warts and donovanosis [18, 19].

The larger skin lesions may mimick lipomas and neurofibromas. The diagnosis in this case was not difficult due to the presence of nasal rhinosporidiosis, the previous experience of encountering such skin lesions occurring separately [1-3], and the common occurrence of this condition in this region [4]. Confirmation was by FNAC and skin biopsy. FNAC, to demonstrate the sporangia and the endospores, can be a fast and an important method to confirm the diagnosis, as shown earlier [1].

How and why such polymorphous lesions occurred, is difficult to explain. The dissemination from nasal lesions was probably through autoinoculation through contaminated fingers used for nose picking or through haematogenous dissemination, as has also been suggested in earlier reports [12]. The localization of the skin lesions to cooler areas of the body (like the leg and the forearm in this case), might be due to the lower temperature (23 °C), needed by the organism for optimum growth [20]. Scratching with nails or minor trauma might have helped in the discharge of infectious material from the big lesion near the knee joint, resulting in a verrucous growth, which got flattened due to the constant pressure and friction of the clothing.

Giant subcutaneous and verrucoid lesions in this condition have been described occurring separately in different patients [1-3, 8-10, 12, 18, 20]. However, coexistence of two different morphological types in the same patient and at the same site has not been documented earlier in the literature. The present report re-emphasizes the diverse manifestations of cutaneous rhinosporidiosis, which may sometimes baffle the uninitiated dermatologist.

References

1 Ramanan C, Ghorpade A. Giant cutaneous rhinosporidiosis. Int J Dermatol 1996; 35: 441-3.

2 Ghorpade A, Ramanan C. Verrucoid cutaneous rhinosporidiosis. J Eur Acad Dermatol Venereol 1988; 10: 269-70.

3 Ghorpade A. Giant cutaneous rhinosporidiosis. J Euro Acad Dermatol Venereol (Under publication).

4 Darbari BS, Gupta RL, Shukla M, et al. Rhinosporidiosis in Raipur. A clinicopathological study of 348 cases. Ind J Pathol Bacteriol 1972; 15: 103-7.

5 Von Haecke NP, Mugliston TAH. Rhinosporidiosis. J Laryngol Otol 1982; 96: 743-50.

6 Lewis GM, Hopper ME, Wilson JW, Plunkett OA. Rhinosporidiosis. In: An Introduction To Medical Mycology, 4rth. Ed. Chicago: The yearbook publishers Inc, 1958: 206.

7 Makannavar JH, Chavan SS. Rhinosporidiosis-a clinicopathological study of 34 cases. Ind J Pathol Microbiol 2001; 44: 17-21.

8 Kavishwar VS, Naik LP, Vora IM. Fine needle aspiration diagnosis of subcutaneous and osteolytic rhinosporidiosis. Cytopathol 1998; 9: 215-7.

9 Kumari R, Laxmisha C, Thappa DM. Disseminated cutaneous rhinosporidiosis. Dermatol Online J 2005; 11: 19-22.

10 Angunavela P, Tissera AD, Dissanayake AS. Rhinosporidiosis presenting with two soft tissue tumors followed by dissemination. Pathol 1999; 31: 57-8.

11 Shreshtha SP, Hennig A, Parija SC. Prevalence of rhinosporidiosis of the eye and its adenexa in Nepal. Am J Trop Med Hyg 1998; 59: 231-4.

12 Thappa DM, Venkatesan S, Sirka CS, Jaishankar TJ. Gopalkrishnan, Ratnakar C. Disseminated cutaneous rhinosporidiosis. J Dermatol 1998; 25: 527-32.

13 Arora R, Ramachandran V, Raina U, Mehta DK. Oculosporidiosis in northern India. Ind Ped 2001; 38: 540-3.

14 Nerurkar NK, Bradoo RA, Joshi AA, Shah J, Tandon S. Lacrimal sac rhinosporidiosis: a case report. Am J Otolaryn 2004; 25: 423-5.

15 Kini U, Amirtham U, Shetty SC, Balasubramany AM. Rhinosporidiosis of the parotid duct cyst: cytomorphological diagnosis of an unusual extranasal presentation. Diagn Cytopathol 2001; 25: 244-7.

16 Sah SP, Singh RK, Ashok Raj G. Urethral rhinosporidiosis: report of a case presenting with a penile growth and urethral fistula. Tran Roy Soc Trop Med Hyg 1999; 93: 298-9.

17 Chao SS, Loh KS. Rhinosporidiosis: an unusual cause of nasal masses gains prominence. Singapore Med J 2004; 45: 224-6.

18 Acharya PV, Gupta RL, Darbari BS. Cutaneous rhinosporidiosis. Ind J Dermatol Venereol Leprol 1973; 39: 22-5.

19 Yesudian P. Cutaneous rhinosporidiosis mimicking verruca vulgaris. Int J Dermatol 1988; 27: 47-9.

20 Laxmisha C, Thappa DM. Subcutaneous swellings due to rhinosporidiosis. J Dermatol 2005; 32: 150-2.