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Guide to Rhinosporidiosis Diagnosis and Treatment
- 1. RHINOSPORIDIOSIS By Dr Basavaraj Patil DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 2. • Introduction • History • Incidence • Mode of spread • Life cycle • Cardinal features • Clinical manifestations • Investigations • Treatment. DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 3. Introduction • Rhinosporidiosis is a chronic granulomatous infective disorder caused by Rhinosporidium seeberi, whose taxonomy is still debated DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Sinha A, Phukan JP, Bandyopadhyay G, et al. Clinicopathological study of rhinosporidiosis with special reference to cytodiagnosis. J Cytol. 2012;29(4):246–249. doi:10.4103/0970-9371.103943
- 4. History &Taxonomy • 1892- regarded as a sporozoan by Malbran, its discoverer, in nasal polyp • 1900- Protozoan by Guillermo Seeber who first published a description of the pathogen • 1923- Phycomycete by Ashworth • Herr et al classified the organism in a new clade -Mesomycetozoa, which includes fish and amphibian pathogens in the former DRIP clade (Dermocystidium, the rossette agent, Ichthyophonus and Psorospermium). • 1953 - Demellow described the mode of its transmission DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Indian Journal of Medical Microbiology, (2002) 20 (3):119-131
- 5. INCIDENCE AND GEOGRAPHICAL DISTRIBUTION India and Sri Lanka. DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Sinha A, Phukan JP, Bandyopadhyay G, et al. Clinicopathological study of rhinosporidiosis with special reference to cytodiagnosis. J Cytol. 2012;29(4):246–249. doi:10.4103/0970-9371.103943
- 6. Hypothesized Mode of Spread Theories • Demellow's theory of direct transmission. • Autoinoculation theory of Karunarathnae (responsible for satellite lesions). • Haematogenous spread - to distant sites DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Prakash M, Johnny JC. Rhinosporidiosis and the pond. J Pharm Bioallied Sci. 2015;7(Suppl 1):S59–S62. doi:10.4103/0975-7406.155804
- 7. Classifications • Nose and nasopharynx were the most commonly affected sites (74.6%), • followed by eye (19%). • Other rare sites accounted for (6.3%) Lips, Palate, Uvula, Maxillary Antrum, Epiglottis, Larynx, Trachea, Bronchus, Ear, Scalp, Vulva, Penis, Rectum and Skin DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Sinha A, Phukan JP, Bandyopadhyay G, et al. Clinicopathological study of rhinosporidiosis with special reference to cytodiagnosis. J Cytol. 2012;29(4):246–249. doi:10.4103/0970-9371.103943
- 8. Reasons for endemicity: • Aquatic micro-organisms might also be relevant to a possible synergistic action in the establishment of natural rhinosporidiosis. * • Blood group studies indicate that rhinosporidiosis is common in patient's with group O (70%), the next high incidence was in group AB.** • Cultureal practice** • Climatic conditions** • Physiochemical properties of water** DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI *Indian Journal of Medical Microbiology, (2002) 20 (3):119-131 **Prakash M, Johnny JC. Rhinosporidiosis and the pond. J Pharm Bioallied Sci. 2015;7(Suppl 1):S59–S62. doi:10.4103/0975-7406.155804
- 9. LIFE CYCLE DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 10. Cardinal features The cardinal features of rhinosporidiosis are 1. Chronicity 2. Recurrence 3. Dissemination DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 11. REASONS FOR CHRONICITY • Antigen sequestration • Antigenic variation • Immune suppression • Immune distraction • Binding of host immunoglobulins DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 12. Clinical manifestations DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Sinha A, Phukan JP, Bandyopadhyay G, et al. Clinicopathological study of rhinosporidiosis with special reference to cytodiagnosis. J Cytol. 2012;29(4):246–249. doi:10.4103/0970-9371.103943
- 13. Karthikeyan P, Vijayasundaram S, Pulimoottil DT. A Retrospective Epidemiological Study of Rhinosporidiosis in a Rural Tertiary Care Centre in Pondicherry. J Clin Diagn Res. 2016;10(5):MC04–MC8. doi:10.7860/JCDR/2016/17465.7788 DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 14. Gross features DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Sinha A, Phukan JP, Bandyopadhyay G, et al. Clinicopathological study of rhinosporidiosis with special reference to cytodiagnosis. J Cytol. 2012;29(4):246–249. doi:10.4103/0970-9371.103943
- 15. • HISTOLOGY DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI Sinha A, Phukan JP, Bandyopadhyay G, et al. Clinicopathological study of rhinosporidiosis with special reference to cytodiagnosis. J Cytol. 2012;29(4):246–249. doi:10.4103/0970-9371.103943
- 16. Investigations • Histology is the mainstay of diagnosis. • A diagnosis of the disease can be made by simple aspiration cytology, the examination of aspirated material with Gomori methenamine silver and periodic acid–Schiff reaction, and the presence of the organism indifferent stages of maturation even in the absence of a histopathological study. • It has to be differentiated from coccidiomycosis. • Endospores of coccidiomycosis have sporangia of smaller size. DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 17. TREATMENT • SURGICAL – endoscopic excision and cauterization of the base -laser excision • MEDICAL Dose of Dapsone- 100 mg once daily for 6 months to several years.Check LFT and blood counts every 2 weeks. DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 18. Conclusion • Rhinosporidiosis shows both long duration & tendency for recurrence. • Recurrent seeding of circulation with spores from nose & nasopharynx may lead to involvement of non mucosal sites. • Trans epithelial infection is also important for recurrence in sites & extension to nearby sites. • Failure to remove all infected tissues at the time of surgery & implantation of spores in fresh areas of abrasions may cause recurrence. • Removal of growth by snare without cauterisation was considered to result in dissemination & recurrence. • Good result obtained with diathermy was explained on the basis that it avoids implantation of spores & destruction is deep. DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
- 19. THANK YOU DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY INHS ASVINI
Editor's Notes
- R seeberi, aquatic protozoan previously considered to be a fungus. Infection affects nasal mucous membranes and ocular conjunctivae of humans and animals, producing slowly growing masses that degenerate into polyps.
- Through molecular biological analysis of the organism’s ribosomal DNA known to medicine since 1900 following its first description by Guillermo Seeber in Buenos Aires, Argentina, who proposed the infective aetiology for this disease to be a fungus, which was later isolated by Ashworth in 1923, who in turn described the life cycle of the organism and established the nomenclature Rhinosporidium seeber
- Male have more outdoor activities
- Demellow.s- He postulated that infection always occured as a result of direct transmission of the organsim. Karunarathnae accounted for satellite lesions in skin and conjunctival mucosa as a result of auto inoculation. Karunarathnae also postulated that Rhinosporidium existed in a dimorphic state.
- There are examples of such synergism of bacteria, with parasites - lactobacilli with Trichomonas, and Wolbachia with filarial nematode
- Spore or spherule- comet of Beattee. 7a- electron dense bodies 7b-electron dense bodies surrounded by nutritive granule. 4a,b- centrifugal and centripetal maturation of endospores
- Though anti-rhinosporidial humoral and cell mediated immune responses do occur in human rhinosporidiosis, there are indications that R.seeberi evades specific adaptive immunity through several mechanisms which might explain some hitherto(until now) enigmatic(mysterious) aspects of rhinosporidiosis viz., chronicity, recurrence and dissemination:
- Antigenic sequestration- impervious to exit of endosporal antigen and also immune destruction Immune supprestion – possible release of immune suppressor agents
- Lesions in the nose can be polypoidal, reddish and granular masses. They could be multiple pedunculated and friable. They are highly vascular and bleed easily. Their surface is studded with whitish dots (sporangia)
- Histopathological sections show multiple sporangia in various stages of maturity, enclosed in a thin chitinous wall. The sporangia are 50-1000 µm in diameter, containing numerous endospores of diameter 5-10 µm. Overlying epithelium is usually hyperplastic and loose fibrovascular stroma infiltrated with lymphocytes, macrophages, plasma cells and even polymorphonuclear leucocytes