Example Of Case Study On Aspergillus Case Study
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A 27 year old male who is a construction worker by profession presented in the clinic with complaints of nasal obstruction and inability to breathe. He has been generally well but develops runny nose every now and then with persistent cough. He also complaints of headache and feeling of pressure built up all over his predominantly around the nose and eyes but never felt significant pain. He also mentions that his flu has always stayed for almost forever and seldom goes away even after heavy and prolonged doses of antibiotics. He also adds that he has been prescribed many nasal preparations in the past but none has relieved his symptoms. He also noticed that his left eye is slightly bulged outwards as compared to his right eye for the past few weeks.
Same Day Tests:
On examination, the left nasal cavity is occluded with pearly grey, grape like growth. The nasal mucosa is erythematous and inflamed with a lot of secretions. His perinasal area and forehead is tender to touch.
Blood sample sent came out with mild easoniphilia. It showed:
Hemoglobin: 14 mg/dL
WBC count: 10000/μL
Differential count: 55% neutrophils, 34% lymphocytes, 5% monocytes, 5% eosinophils, 1% basophils.
Platelet count: 400,000/ μL
X-ray (Water’s View): showed opacification of the frontal and maxillary sinuses.
Possible diagnoses considered are:
Diagnosis was made by:
Mucus sample was taken during the examination of nasal cavity and was sent for analysis along with the histopathology sample.
On H&E staining, inflammatory infiltrates predominantly abundant in eosinophils, lymphocytes, and plasma cells. The mucosal layer is hyperplastic and hypertrophied with no granuloma or necrosis seen.
It is a reliable indicator of the disease and on gross examination; it is thick, viscous and variably colored. It resemble to peanut butter or axle grease. On microscopic examination, mucin resembles hyaline appearance with Charcot-Leyden crystals laden eosinophils. These eosinophils are in the form of sheets and can be visualized on H&E staining. Fungal hyphae were also noted.
Further, a CT scan should be done ideally to assess the extent of the disease and to make a proper diagnosis which may show unilateral or asymmetric involvement with mucosal thickening and hyperdense areas.
An MRI should always be added with CT and it shows peripheral enhancement on T1 and T2 series. Due to cross linking, T1 central hypointensity and T2 central signal void is seen on MRI.
Fungal culture is also helpful in the assessment of the disease. Total Immunoglobulin E (IgE) levels are generally raised often to more than 1000 U/mL.
The patient has history of exposure to industrial molds and hypersensitivity. He also has developed mild proptosis and has a polyp in the left nasal cavity. The x-ray showed opaque sinuses with high IgE levels and eosinophilia. Mucin analysis showed fungal hyphae and eosinophils laden with Charcot-Leyden crystals. CT and MRI showed mucosal thickening with hyperdense areas and are pointing towards Fungal Sinusitis. Raised IgE and a history of chronic rhinosinusitis is suggestive of allergic etiology of the disease. So, the diagnosis, of Allergic Fungal Sinusitis (AFS) was made and patient was treated with the following.
Mainstay of the treatment is endoscopic surgical debridement and clearance with provision of ventilation and drainage. It is followed by low dose oral steroids and use of topical steroids. Patients are also advised to aggressively wash their nasal cavity with salt-water. Patient has a good prognosis because the disease is non-invasive. Although, he has a high risk occupation and therefore should do something regarding to it.
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