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Table of Contents 
CASE REPORT
Year : 2016  |  Volume : 61  |  Issue : 2  |  Page : 209-212
Varied presentations of cutaneous rhinosporidiosis: A report of three cases


1 Department of Dermatology, Cutis Institute of Dermatology and Aesthetic Sciences, Calicut, Kerala, India
2 Department of Dermatology, Chest Hospital, Calicut, Kerala, India

Date of Web Publication1-Mar-2016

Correspondence Address:
Thurakkal Salim
Cutis Institute of Dermatology and Aesthetic Sciences, Pottammal, Calicut - 673 016, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.177750

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   Abstract 

Rhinosporidiosis is a chronic granulomatous disorder of infective etiology and it frequently affects the nasal cavity and nasopharynx. Involvement of skin in rhinosporidiosis is unusual and it may manifest itself in a diverse manner mimicking several common dermatological conditions. Three cases of cutaneous rhinosporidiosis with different presentations are reported here to highlight the manifold nature of the condition. Cutaneous rhinosporidiosis can mimic several common cutaneous disorders.


Keywords: Cutaneous rhinosporidiosis, furunculoid, nonhealing ulcer, subcutaneous, urethral rhinosporidiosis


How to cite this article:
Salim T, Komu F. Varied presentations of cutaneous rhinosporidiosis: A report of three cases. Indian J Dermatol 2016;61:209-12

How to cite this URL:
Salim T, Komu F. Varied presentations of cutaneous rhinosporidiosis: A report of three cases. Indian J Dermatol [serial online] 2016 [cited 2019 May 24];61:209-12. Available from: http://www.e-ijd.org/text.asp?2016/61/2/209/177750

What was known?
Cutaneous rhinosporidiosis has different morphological presentations.



   Introduction Top


Rhinosporidiosis is a chronic granulomatous disorder of infective etiology frequently affecting the nasal mucosa and the nasopharynx (70%).[1] Though cutaneous lesions in rhinosporidiosis are rare, they may simulate many common dermatological conditions thus posing a diagnostic dilemma. Three cases of cutaneous rhinosporidiosis with varied modes of presentation are reported here to emphasize the manifold nature of the condition.


   Case Reports Top


Case 1

A 52-year-old manual laborer presented with a painless swelling over the left side of the chest of 4 months duration which was gradually increasing in size. He also gave a history of surgery for a polypoidal mass in the nose 1-year back which recurred after 3 months. He also gave a history of bathing in ponds regularly over the past 20 years.

A solitary swelling (2 cm × 1.5 cm × 1.5 cm) with surrounding erythema and tenderness was observed over the left side of chest [Figure 1]. The overlying skin was fixed to the swelling. Nasal examination showed bright red polypoidal masses at the right anterior nare [Figure 2]. System examination revealed no abnormality. Fine needle aspirate on 10% KOH revealed sporangia in different stages of development. Histological examination of the swelling showed multiple thick-walled sporangia at various levels of maturation [Figure 3]. A diagnosis of subcutaneous rhinosporidiosis was made. The nasal and cutaneous swellings were surgically excised, and the base cauterized. He was treated with dapsone 100 mg daily for 6 months. There was no recurrence at the end of 8 months.
Figure 1: Subcutaneous swelling over left side of chest

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Figure 2: Polypoidal mass hanging from right nostril

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Figure 3: Histopathology showing multiple thick walled sporangia in various stages of maturation (H and E, ×40)

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Case 2

A 47-year-old fisherman came with an asymptomatic pedunculated mass protruding from the external urethral meatus of 1 1/2 year duration. He was treated surgically 1-year back followed by recurrence after 3 months. He gave a history of bathing in ponds occasionally.

A soft pedunculated swelling of 1.5 cm × 1 cm × 1 cm size originating from the wall of the external urethral meatus was observed [Figure 4]. There were no other skin or mucosal lesions noted elsewhere. Histopathology showed features of rhinosporiodiosis. The swelling was excised and the base electrodessicated leading to total resolution. He was given dapsone 100 mg OD for 6 months. However, the swelling recurred after 4 months which were again treated surgically. This was followed by a recurrence after 6 months.
Figure 4: Soft, pedunculated swelling at the external urethral meatus

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Case 3

A 29-year-old man presented with a nonhealing ulcer over the anterior aspect of the right leg of 4 months duration for which he was treated with various antibiotics and topical medications. He also complained of a fleshy lesion in the mouth for the last 2 years. He gave a history of bathing in a pond for the last 7 years.

There was an irregular ulcer measuring 6 cm × 3.5 cm over the anterior aspect of right leg showing peripheral healing and central red granulation tissue [Figure 5]. On close examination, small brownish spots were observed. Oral examination showed a pedunculated red mass studded with black spots hanging by the side of the uvula [Figure 6]. Histopathologic examination of both the lesions revealed features of rhinosporidiosis. Both the lesions were surgically excised, and the base of the ulcer was treated by radiofrequency ablation. The patient was further started on dapsone 100 mg OD. On follow-up, the ulceration healed but new oral lesions were noted after 3 months.
Figure 5: Nonhealing ulcer over anterior aspect of right leg

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Figure 6: Mass hanging by the side of uvula

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   Discussion Top


Guillermo Seeber, who first described the organism in 1890's, considered the sporangium of Rhinosporidium seeberi to be a sporozoan.[2] Recently, Ahluwalia et al., suggested, however, that the causative agent of rhinosporidiosis is the cyanobacterium Microcystis aeruginosa.[3]

Rhinosporidiosis is more common in males and is usually seen between the second and fourth decade. Exposure to stagnant water, bathing in water in which cattle are also bathed, and repeated trauma have been blamed for its acquisition.[4]

Rhinosporidiosis presents most frequently as polypoidal lesions in the nasal cavity. Sites like the conjunctiva, oral cavity, trachea, skin, and genitourinary tract are less frequently involved.[5]

The mode of spread of rhinosporidiosis to the skin can be by three means:[1],[6]

  • Autoinoculation: This explains the occurrence of satellite lesions adjacent to the nasal lesions
  • Hematogenous spread: The development of skin lesions distant to the nasal lesions as is seen in Case 1 and 3 could be due to a hematogenous spread of the infection
  • Direct inoculation of the organism in traumatized skin, also known as the primary cutaneous type. The occurrence of a pedunculated mass at the external urethral meatus in Case 2 without any lesions elsewhere is probably due to direct inoculation.


Cutaneous lesions in rhinosporidiosis have been reported as pedunculated or sessile growths,[7] verruca vulgaris like lesions,[1],[5],[8] friable nodular lesions,[5],[6] subcutaneous swellings,[6],[9] furunculoid lesions,[5] cutaneous horn,[5] shiny globular swellings,[6] cutaneous ulceration,[10] and cystic swellings.[11] Thus, it can be observed that rhinosporidiosis has a multi-faceted presentation in the skin. The various differential diagnoses include warts, verrucous tuberculosis and granuloma pyogenicum.

Case 1 in our series showed a furunculoid swelling over the chest with an associated nasal polyp. Furunculoid lesions have been reported previously by Kumari et al.[5] in a case of disseminated rhinospodiosis.

Case 2 presented with a pedunculated mass at the external urethral meatus. The genitourinary tract is an extremely rare site of involvement, and only few cases have been reported till date.[12] It can occur as a part of disseminated rhinosporidiosis but, in this case, no other lesions were noted and hence may be due to a direct inoculation.

Cutaneous ulceration as was noted in Case 3 is a rare occurrence in rhinosporidiosis and this can lead to misdiagnosis and subsequent incorrect management. A close observation of the ulcer in Case 3 revealed brownish spots which could be similar to the whitish spots observed in polyps representing sporangia. Primary cutaneous ulceration was reported by Hadke et al.[10] Generally, ulceration in cutaneous rhinosporidiosis occurs secondarily in a verrucous plaque [13] or a swelling.

Though spontaneous regression can rarely occur,[13] lesions may persist for a long time if untreated.

As the organism cannot be grown in culture, histopathology is the gold standard.[6] Biopsy reveals a hyperplastic epithelium with a chronic inflammatory cell infiltrate composed of plasma cells, lymphocytes along with foreign body giant cells. Characteristic sporangia in various stages of maturation are seen as globular cysts of various sizes lined by well-defined wall containing endospores. Giemsa imprinted smears and a fine needle aspirate with 10% KOH examination are also helpful.[1]

Rhinosporidiosis may be medically managed with dapsone which is believed to arrest the maturation of the sporangia and induce fibrosis in the stroma. However, it remains an adjunct to surgical removal and electrodessication which remain the treatment of choice.[1],[14]


   Conclusion Top


Cutaneous rhinosporidiosis is a disease with a multi-faceted presentation which might pose a diagnostic puzzle as it mimics several common skin disorders. A search for nasal or oral lesions and an enquiry into the history of the same is imperative when faced with such presentations. A simple KOH examination could help clinch the diagnosis. The present article asserts the diverse clinical manifestations of cutaneous rhinosporidiosis, which may at times faze the clinician.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kumari R, Laxmisha C, Thappa DM. Disseminated cutaneous rhinosporidiosis. Dermatol Online J 2005;11:19.  Back to cited text no. 1
    
2.
Fredricks DN, Jolley JA, Lepp PW, Kosek JC, Relman DA. Rhinosporidium seeberi: A human pathogen from a novel group of aquatic protistan parasites. Emerg Infect Dis 2000;6:273-82.  Back to cited text no. 2
    
3.
Ahluwalia KB, Maheshwari N, Deka RC. Rhinosporidiosis: A study that resolves etiologic controversies 1997;11:479-83.  Back to cited text no. 3
    
4.
Ghorpade A. Polymorphic cutaneous rhinosporidiosis. Eur J Dermatol 2006;16:190-2.  Back to cited text no. 4
    
5.
Kumari R, Nath AK, Rajalakshmi R, Adityan B, Thappa DM. Disseminated cutaneous rhinosporidiosis: Varied morphological appearances on the skin. Indian J Dermatol Venereol Leprol 2009;75:68-71.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Nayak S, Acharjya B, Devi B, Sahoo A, Singh N. Disseminated cutaneous rhinosporidiosis. Indian J Dermatol Venereol Leprol 2007;73:185-7.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Thappa DM, Venkatesan S, Sirka CS, Jaisankar TJ, Gopalkrishnan, Ratnakar C. Disseminated cutaneous rhinosporidiosis. J Dermatol 1998;25:527-32.  Back to cited text no. 7
    
8.
Ghorpade A, Ramanan C. Verrucoid cutaneous rhinosporidiosis. J Eur Acad Dermatol Venereol 1998;10:269-70.  Back to cited text no. 8
    
9.
Ghorpade A. Giant cutaneous rhinosporidiosis. J Eur Acad Dermatol Venereol 2006;20:88-9.  Back to cited text no. 9
    
10.
Hadke NS, Baruah MC. Primary cutaneous rhinosporidiosis. Indian J Dermatol Venereol Leprol 1990;56:61-3.  Back to cited text no. 10
  Medknow Journal  
11.
Tolat SN, Gokhale NR, Belgaumkar VA, Pradhan SN, Birud NR. Disseminated cutaneous rhinosporidiomas in an immunocompetent male. Indian J Dermatol Venereol Leprol 2007;73:343-5.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.
Pal DK, Moulik D, Chowdhury MK. Genitourinary rhinosporidiosis. Indian J Urol 2008;24:419-21.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.
Shenoy MM, Girisha BS, Bhandari SK, Peter R. Cutaneous rhinosporidiosis. Indian J Dermatol Venereol Leprol 2007;73:179-81.  Back to cited text no. 13
[PUBMED]  Medknow Journal  
14.
Vijaikumar M, Thappa DM, Karthikeyan K, Jayanthi S. A verrucous lesion of the palm. Postgrad Med J 2002;78:302, 305-6.  Back to cited text no. 14
    

What is new?
This article highlights the diverse manifestations of cutaneous rhinosporidiosis and stresses the need to consider the same as a differential diagnosis in common skin conditions especially in endemic areas.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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    Abstract
   Introduction
   Case Reports
   Discussion
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    References
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