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Clinical findings of laryngeal aspergillosis
CLINICAL PHOTOGRAPHS MICHAEL A. KEEFE, MD, CDR MC USN Clinical Photographs Editor
Clinical findings of laryngeal aspergillosis ANDREA GALLO, MD, VALENTINA MANCIOCCO, MD, MARILIA SIMONELLI, MD, ANTONIO MINNI, MD, and MARCO DE VINCENTIIS, MD, Rome, Italy
A spergillosis is generally considered an opportunist mycosis because it is usually a significant cause of morbidity and mortality only in the immunocompromised host. More than 80% of cases involve the lung, followed by the brain, the gastrointestinal tract, and the kidneys. Head and neck manifestations include nasal, paranasal, and otologic diseases. Aspergillosis of the larynx is uncommon and is usually secondary to pulmonary involvement. Primary laryngeal involvement by Aspergillus has been reported but is extremely rare. Felty’s syndrome is a clinical variant of rheumatoid arthritis. Herein we report the clinical appearance of the first case of primary aspergillosis of the larynx in a patient with Felty’s syndrome. CASE REPORT A 53-year-old male florist reported an intermittent fever of 2 weeks’ duration and hoarseness of 10 days’ duration. The patient’s medical history was significant for a 12-year history of rheumatoid arthritis, for which he was being treated with steroids. As result of the progressive hoarseness, he was referred to an ENT consultant. Examination of the ears, nose, and oropharynx revealed no abnormalities. Fiberoptic laryngoscopy revealed white plaques involving the upper surface of both true vocal cords (Fig 1). The surrounding mucous membrane was normal. The supraglottis appeared normal, and the vocal cords were mobile. Direct laryngoscopy and biopsy were done to obtain histologic specimens and to exclude a neoplasm as the cause of the lesions. During direct laryngoscopy with
This section is made possible through an educational grant from AstraZeneca, LP, makers of Rhinocort Aqua. From the Department of Otorhinolaryngology, “La Sapienza” University (Drs Gallo, Manciocco, Minni, and De Vincentiis); and the I.R.C.C.S. Santa Lucia Hospital (Dr Simonelli). Reprint requests: Andrea Gallo, MD, Via Adolfo Venturi 19, 00162 Rome, Italy. Otolaryngol Head Neck Surg 2000;123:661-2. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/11/110106 doi:10.1067/mhn.2000.110106
the patient under general anesthesia, a large plaque-like, whitish lesion was noted and removed for histologic analysis. The biopsy specimens showed necrosis of the squamous epithelium with numerous fungal hyphae. Tissue culture from the specimens grew Aspergillus flavus. This confirmed the diagnosis of primary aspergillosis of the larynx in a patient with Felty’s syndrome, and treatment with filgrastim and intravenous amphotericin B (1 mg/kg/day) was started immediately. Ten days later, amphotericin B was replaced with oral itraconazole. Two weeks later the patient was discharged, free of aspergillosis. DISCUSSION Primary aspergillosis of the larynx is very rare. In the English language literature, it has been described in 12 otherwise healthy patients,1,2 in 2 patients who had undergone irradiation for laryngeal carcinoma,3 and in 3 immunocompromised patients.4 The infection usually involves the respiratory tract because Aspergillus spores are able to enter with inhaled air. The most common presenting symptom is
Fig 1. White plaques involving the upper surface of both true vocal cords. 661
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Otolaryngology– Head and Neck Surgery November 2000
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hoarseness because of the involvement of the true vocal cords. However, progressive dyspnea is also usually present. Confirmation of the diagnosis of aspergillosis is made by biopsy, which also reveals the neoplastic nature of the lesions. Treatment with intravenous amphotericin B for 2 weeks usually results in regression of the lesions.
REFERENCES 1. Rao PB. Aspergillosis of the larynx. J Laryngol Otol 1969;83:377-3. 2. Nong D, Nong H, Li J, et al. Aspergillosis of the larynx: a report of 8 cases. Chin Med J (Engl) 1997;110:734-6. 3. Beust L, Godey B, Le Gall F, et al. Primary aspergillosis of the larynx and squamous cell carcinoma. Ann Otol Rhinol Laryngol 1998;107:851-4.
Clinical findings of laryngeal aspergillosis ANDREA GALLO, MD, VALENTINA MANCIOCCO, MD, MARILIA SIMONELLI, MD, ANTONIO MINNI, MD, and MARCO DE VINCENTIIS, MD, Rome, Italy
A spergillosis is generally considered an opportunist mycosis because it is usually a significant cause of morbidity and mortality only in the immunocompromised host. More than 80% of cases involve the lung, followed by the brain, the gastrointestinal tract, and the kidneys. Head and neck manifestations include nasal, paranasal, and otologic diseases. Aspergillosis of the larynx is uncommon and is usually secondary to pulmonary involvement. Primary laryngeal involvement by Aspergillus has been reported but is extremely rare. Felty’s syndrome is a clinical variant of rheumatoid arthritis. Herein we report the clinical appearance of the first case of primary aspergillosis of the larynx in a patient with Felty’s syndrome. CASE REPORT A 53-year-old male florist reported an intermittent fever of 2 weeks’ duration and hoarseness of 10 days’ duration. The patient’s medical history was significant for a 12-year history of rheumatoid arthritis, for which he was being treated with steroids. As result of the progressive hoarseness, he was referred to an ENT consultant. Examination of the ears, nose, and oropharynx revealed no abnormalities. Fiberoptic laryngoscopy revealed white plaques involving the upper surface of both true vocal cords (Fig 1). The surrounding mucous membrane was normal. The supraglottis appeared normal, and the vocal cords were mobile. Direct laryngoscopy and biopsy were done to obtain histologic specimens and to exclude a neoplasm as the cause of the lesions. During direct laryngoscopy with
This section is made possible through an educational grant from AstraZeneca, LP, makers of Rhinocort Aqua. From the Department of Otorhinolaryngology, “La Sapienza” University (Drs Gallo, Manciocco, Minni, and De Vincentiis); and the I.R.C.C.S. Santa Lucia Hospital (Dr Simonelli). Reprint requests: Andrea Gallo, MD, Via Adolfo Venturi 19, 00162 Rome, Italy. Otolaryngol Head Neck Surg 2000;123:661-2. Copyright © 2000 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/2000/$12.00 + 0 23/11/110106 doi:10.1067/mhn.2000.110106
the patient under general anesthesia, a large plaque-like, whitish lesion was noted and removed for histologic analysis. The biopsy specimens showed necrosis of the squamous epithelium with numerous fungal hyphae. Tissue culture from the specimens grew Aspergillus flavus. This confirmed the diagnosis of primary aspergillosis of the larynx in a patient with Felty’s syndrome, and treatment with filgrastim and intravenous amphotericin B (1 mg/kg/day) was started immediately. Ten days later, amphotericin B was replaced with oral itraconazole. Two weeks later the patient was discharged, free of aspergillosis. DISCUSSION Primary aspergillosis of the larynx is very rare. In the English language literature, it has been described in 12 otherwise healthy patients,1,2 in 2 patients who had undergone irradiation for laryngeal carcinoma,3 and in 3 immunocompromised patients.4 The infection usually involves the respiratory tract because Aspergillus spores are able to enter with inhaled air. The most common presenting symptom is
Fig 1. White plaques involving the upper surface of both true vocal cords. 661
662
Otolaryngology– Head and Neck Surgery November 2000
GALLO et al
hoarseness because of the involvement of the true vocal cords. However, progressive dyspnea is also usually present. Confirmation of the diagnosis of aspergillosis is made by biopsy, which also reveals the neoplastic nature of the lesions. Treatment with intravenous amphotericin B for 2 weeks usually results in regression of the lesions.
REFERENCES 1. Rao PB. Aspergillosis of the larynx. J Laryngol Otol 1969;83:377-3. 2. Nong D, Nong H, Li J, et al. Aspergillosis of the larynx: a report of 8 cases. Chin Med J (Engl) 1997;110:734-6. 3. Beust L, Godey B, Le Gall F, et al. Primary aspergillosis of the larynx and squamous cell carcinoma. Ann Otol Rhinol Laryngol 1998;107:851-4.