Infectious Disease Pathology
Case 3 -
A Multitude of Mistakes or the Case of the Discarded Fungus
Nebraska Methodist Health System
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73 yr. old woman with chronic left maxillary sinus pain. CT scan of the sinuses showed complete
opacification of the left maxillary sinus with bony erosion in a portion of the medial wall of the
sinus. Chronic infection or malignancy?
Surgical exploration revealed “obvious green and black fungal debris oozing from the maxillary
ostium”. The surgeon sent a swab of the left maxillary curettage specimen for bacterial culture and the
specimen to surgical pathology for histological exam.
A routine bacterial culture was set up and grew two types of Coagulase-negative Staph and rare
Enterobacter cloacae. The direct gram stain showed some cellular debris and a few gram positive
cocci (no segmented WBC seen). The technologist questioned me whether she should do susceptibilities.
Because the swab was a large tipped swab and not a mini-tip, she thought this was not a true sinus
specimen but a nasal specimen and as such, not worthy of work up. She reasoned that a large tip swab
would not be able to go through the maxillary ostiaand would be contaminated by nasal secretions.
Investigation of the case revealed that the surgical pathology report had been signed out as “chronic
sinusitis, NOS” but that the operative report clearly stated that fungus was present, due to the
discrepancy the surgical slide was reviewed. Brown pigmented septate hyphae and conidia were seen.
The surgeon was called and he stated that he didn’t think he needed a fungal culture because he
already knew it was a fungus. If he needed to treat he would use Amphotericin B instillations. He was
educated to the fact that some fungi are intrinsically resistant to Amphotericin and other antifungal
agents. Culture is needed for identification.
A Supplemental pathology report was issued: Review of the slides reveals brown pigmented
septatehyphaeand conidia consistent with a dematiaceous fungus. Definitive invasion of tissue is not
seen. A gram stain shows gram positive cocci primarily in the areas of necrotic debris. They appear
to be colonizing the debris based on location and a lack of acute inflammatory cells associated with
the bacterial organisms. See fungal culture report for definitive ID of fungus present.
The surgeon told us he had, in fact sent us a small piece of tissue which he had jammed down into the
culturette tube with the swab. The culturette tube was retrieved and cut open. A small piece of
tissue was found in the packing material in the bottom of the tube This tissue was set up for fungal
The culture grew Scedosporium apiospermum
|This fungus is the asexual state of Pseudallescheria boydii|
|Often resistant to Amphotericin B and Flucytosine but susceptible to the azoles (including Voriconazole)|
|Comment placed on fungal culture report: These fungi are often resistant to Amphotericin B.|
- Pathology of Hyalohyphomycosiscaused by Scedosporiumapiospermum(Pseudallscheriaboydii) An Emerging Mycosis; Tadroset. al. Human Pathology: Vol29, No. 11 (Nov 1998)
- A Guide to Specimen Management in Clinical Microbiology; J. Michael Miller-2ndedition, ASM Press, 1999
- Fungal Infections of the Nose and Paranasal Sinuses (Parts I andII); Lawson, W. et. al. , OtolaryngologicClinics of North America, Vol. 26; 6: Dec. 1993, pages 1007-1035 and 1039-1068
- Fungal sinusitis; DeShazoet. al. NEJM, Vol337, pg. 254-259, July 24,1997
- Article and posters can be downloaded from following College of American Pathologist’s “CAP Today”website: http://www.cap.org/apps/docs/cap_today/feature_stories/0804Swabs.html.