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CORRESPONDENCE
Year : 2020  |  Volume : 65  |  Issue : 4  |  Page : 325-326
Recurrent disseminated cutaneous rhinosporidiosis - Where is the end?


Department of Dermatology, Government Villupuram Medical College Hospital, Villupuram, Tamil Nadu, India

Date of Web Publication11-Jun-2020

Correspondence Address:
C Chandrakala
Department of Dermatology, Government Villupuram Medical College Hospital, Villupuram, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_164_19

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How to cite this article:
Chandrakala C, Tharini G K. Recurrent disseminated cutaneous rhinosporidiosis - Where is the end?. Indian J Dermatol 2020;65:325-6

How to cite this URL:
Chandrakala C, Tharini G K. Recurrent disseminated cutaneous rhinosporidiosis - Where is the end?. Indian J Dermatol [serial online] 2020 [cited 2020 Jul 8];65:325-6. Available from: http://www.e-ijd.org/text.asp?2020/65/4/325/286389




Sir,

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi, commonly affecting the mucosa of nose, nasopharynx, and soft palate, less commonly the conjunctiva, lacrimal sac, and maxillary sinus. Clinically, it presents as a red polypoidal lesion in the mucosa. It can occur in different morphological patterns in the skin.

A 60-year-old male presented with a red friable lesion on the left side of the forehead, crusted plaques on the right forearm and right leg for 2 months. He was operated for nasal rhinosporidiosis and swelling near the left eye 7 years ago. On examination, there was a red friable polypoidal lesion on the left side of the forehead just above the eyebrow and on the right side of the ala of nose [Figure 1]a and [Figure 1]b. A crusted plaque was noted on the extensor aspect of the right forearm and crusted nodular lesion on the right leg [Figure 1]c and [Figure 1]d. He also had nodules near the left lower eyelid. Scarring was noted at the previously operated site near the left lower eyelid [Figure 1]a. Regional lymph nodes were not enlarged. Scraping and 10% potassium hydroxide (KOH) mount of the lesion showed sporangiospores [Figure 2]a. Complete hemogram and other blood investigations were within normal limits. Serology for HIV was non-reactive. His chest X-ray and ultrasound abdomen were normal. He was referred for excision biopsy of the skin lesions. Histopathological examination of excision biopsy specimens showed mature and immature sporangiospores and numerous endospores against inflammatory background [Figure 2]b. Dermoscopy was not done for the skin lesions. He was prescribed tablet dapsone 100 mg daily for 6 months. During dapsone therapy, he presented with a red friable lesion on the palmar aspect of the left ring finger and a verrucous growth on the dorsum of the right second toe [Figure 3]a and [Figure 3]b and the lesions were excised. The patient took dapsone for 3 months, and he stopped the treatment by himself. One year later, rhinosporidiosis recurred at the thenar eminence of the left palm as a red friable lesion and a verrucous lesion in the medial aspect of the right arm [Figure 3]c and [Figure 3]d. After eight months, he developed a crateriform lesion with central polypoidal growth over the left forearm and a nodular lesion over the chest [Figure 4]a and [Figure 4]b. Excision biopsy of all the lesions showed sporangiospores on histopathological examination. After excision of the lesions, the patient was advised to take Dapsone 100 mg daily. Our patient had multiple cutaneous recurrences with varied morphological patterns in spite of intermittent dapsone therapy.
Figure 1: (a): Red friable polypoidal lesion on the forehead. (b): Crusted lesion on the ala of the nose. (c): Crusted plaque on the extensor aspect of the right forearm. (d): Crusted nodular lesion on the right leg

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Figure 2: (a): Sporangiospore in KOH mount (×100). (b): Skin biopsy showing mature and immature sporangiospores and numerous endospores against an inflammatory background (H and E, ×100)

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Figure 3: (a): Red friable lesion on the palmar aspect of the left ring finger. (b): Verrucous growth on the dorsum of the right second toe. (c): Recurrence in the thenar eminence of the left palm. (d): Verrucous lesion in the medial aspect of the right arm

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Figure 4: (a): Keratoacanthoma-like crateriform lesion. (b): Nodular lesion over the chest

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The four common clinical types of rhinosporidiosis are nasal, ocular, disseminated, and primary cutaneous forms; among these, the primary cutaneous type is very rare.[1] Cutaneous rhinosporidiosis commonly occurs with primary lesions in the nose, nasopharynx, or lacrimal apparatus. Four different modes of spread have been described for rhinosporidiosis which include autoinoculation, hematogenous dissemination, lymphatic spread, and direct inoculation into the skin.[2] Unless there is a history of primary nasal or ocular rhinosporidiosis, skin lesions may be overlooked as they occur in different morphological forms. The various cutaneous forms described include lesions resembling pyogenic granulomas,[3] furuncles, ecthyma, lipomas, soft tissue tumors,[4] tuberculosis verrucosa cutis, viral warts, donovanosis, subcutaneous nodules, cutaneous horn,[5] and subcutaneous giant masses. Surgical excision followed by cauterization is the preferred treatment method for cutaneous rhinosporidiosis.[5] The cutaneous recurrences in immunocompetent individuals are probably due to inadequate excision and autoinoculation. Dapsone is used as an adjuvant to surgical excision and it acts by inhibition of maturation of sporangiospores and increases fibrosis in the stroma.[6]

The different morphological forms of skin lesions occurred in our patient were red friable growth, crusted plaque, nodule, verrucous lesion, and keratoacanthoma-like crateriform lesion. This case is reported for the occurrence of recurrent cutaneous lesions in various morphological patterns along with keratoacanthoma-like skin lesion, which has not been reported in the literature so far.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mandal SK, Dutta S, Roy S. Cutaneous Rhinosporidiosis. Indian J Dermatol 2000;45:78-80.  Back to cited text no. 1
    
2.
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. 2
[PUBMED]  [Full text]  
3.
Sahu B, Sahu P, Puhan MR. Disseminated cutaneous rhinosporidiosis: A polymorphic presentation in an immunocompetent patient. Indian J Dermatol 2015;60:218.  Back to cited text no. 3
    
4.
Date A, Ramkrishna B, Lee VN, Sundraraj GD. Tumoral rhinosporidiosis. Hiatopathology 1995;27:288-90.  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]  [Full text]  
6.
Job A, Venkateswaran S, Mathan M, Krishnaswami H, Raman R. Medical therapy of rhinosporidiosis with dapsone. J Laryngol Otol 1993;107:809-12.  Back to cited text no. 6
    


    Figures

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



 

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