Neelima Gupta

Nasal rhinosporidiosis in humans: new interpretations and a review of the literature of this enigmatic disease

Rhinosporidiosis is a disease caused by Rhinosporidium seeberi which primarily affects the mucosa of the nose, conjunctiva and urethra. While it is endemic in some Asian regions, isolated cases are reported in other parts of the world as a result of the socio-cultural phenomenon of the migration. Its manifestation is a polypoid mass growing inside the affected cavity and the only treatment is surgical excision. Rhinosporidiosis is a condition which both clinicians and microbiologists should keep in mind when managing patients with nasal masses even those from non endemic areas. It is critical in such cases to follow the clinical course to ensure against recurrence of the disease. This study describes the clinical features, diagnosis, and treatment of rhinosporidiosis of the nose and nasopharynx in a series of three cases in East Delhi, India.

Position Paper on Olfactory Dysfunction

Background Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: • Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. • Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. • Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. • Comprehensive chemosensory assessment should include gustatory screening. • Smell training can be helpful in patients with olfactory loss of several aetiologies. Conclusions We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Basidiobolomycosis of the Nose and Face: A Case Report and a Mini-Review of Unusual Cases of Basidiobolomycosis

BackgroundSubcutaneous zygomycosis is a chronic infection caused by fungus of the order Entomophthorales. It can have varying presentations and presents in the nose and face area with gradually progressing subcutaneous swelling that may be difficult to diagnose unless a strong suspicion of fungal involvement is maintained. We present a case of subcutaneous zygomycosis in a 35-year-old male patient, resident of a North Indian state. The patient was diagnosed to be suffering from subcutaneous zygomycosis, the causative agent being Basidiobolus ranarum identified on culture and lactophenol cotton blue mount preparation. He responded well to treatment with Itraconazole and Terbinafine and is asymptomatic on follow-up.ConclusionsInvolvement of the nose and subcutaneous tissues of the face in Basidiobolomycosis is rare. The infection is more common in children, but the case presented here is an adult. Its occurrence in a native of North India is also uncommon. Previous studies have mostly reported good response to potassium iodide therapy. Our patient responded well to Itraconazole. The presentation can be a diagnostic dilemma if fungal smear and culture is not sought, so this rare entity should be kept in mind in cases of indolent infections of the nose and facial soft tissues.

Frequency of fungal isolation and antifungal susceptibility pattern of the fungal isolates from nasal polyps of chronic rhinosinusitis patients at a tertiary care centre in north India

Sinonasal polyposis is considered to be the end-result of a chronic inflammatory process in the sinonasal mucosa. Its underlying mechanisms are still unclear, but the involvement of fungi has been suggested for many years. In the present study, we retrospectively evaluated the clinical and mycological profile of 161 patients with chronic rhinosinusitis (CRS) and nasal polyps who were undergoing surgery at our tertiary care facility during 2002 to 2010. CT scan findings and per-operative presence of allergic mucin were provisionally suggestive of fungal rhinosinusitis (FRS) in all the patients. Total serum IgE and peripheral eosinophilia were noted. Histological examination of polyp tissue showed eosinophilic mucin in 100% of the cases and the incidence of allergic fungal rhinosinusitis (AFRS) was 83.9% in the patient population. KOH and/or culture were positive for fungal hyphae or yeast in 93% (150/161) of the patients. Aspergillus spp. were the most commonly recovered isolates (70%). MICs of all A. flavus and A. fumigatus isolates were within the susceptible zone for itraconazole, voriconazole, and amphoterecin B. In conclusion, allergic fungal rhinosinusitis (FRS) is a common disorder in patients with sinonasal polyposis and due to its recurrent and intractable nature, a high degree of clinical suspicion for the presence of FRS in nasal polyposis should be considered.

Fungal profile of clinical specimens from a tertiary care hospital

Abstract Objective To investigate the prevalence of some common fungal infections in relation to the site of involvement over one year period from a tertiary care hospital. Methods Samples were collected from the patients presenting with clinically suspected fungal infections. Direct microscopy with KOH was done to visualize presence of any fungal element and gram staining was done for any suspected yeast infection. For fungal culture all samples were inoculated on two isolation media; one sabourauds dextrose agar (SDA) and the other SDA with chloramphenicol and cycloheximide. Results A total of 2 228 samples from various infections suspected of fungal etiology were received during the one year period of analysis, out of which nail was the most frequent. Dermatophytes were found to be most frequent fungal isolates. Conclusions There are distinct patterns of geographical variation in the etiology of fungal infections and it is essential to determine the local etiology within a given region when planning a management strategy

Generating an evidence base for information, education and communication needs of the community regarding deafness: A qualitative study

Background: India is a significant contributor to the world’s total burden of deafness. Out of all causes, almost 50% of the causes of decreased hearing are preventable. With the launch of the National Programme for Prevention and Control of Deafness, the need for an effective information, education and communication (IEC) campaign was felt. There is negligible information available about the status of awareness levels of the community about the various aspects of hearing loss. We carried out this research with the objective of getting to know the existing awareness related to hearing loss in the community to generate an evidence base for formulating various messages to be incorporated in IEC materials for dissemination in the community. We also asked the participants about their suggestions for the various information resources so that an IEC campaign could be designed accordingly. Materials and Methods: We carried out 10 focus group discussions among various groups of population and analyzed the discussion. Results: A descriptive analysis of the observations regarding the awareness about deafness in the community and prevalent myths and suggested information resources is presented. Conclusion: We highlight the lacunae in the existing awareness of various causes of deafness and the preventive measures that could be taken to prevent hearing loss. The evidence generated was used to formulate relevant messages for the various target groups, which were then incorporated in development of the IEC materials for the dissemination in the community.

Parapharyngeal space lipoma

I ipomas of the Para-pharyngeal space are rare lesions Very few cases of such tumors have be en reported in the literature Definitive diagnosis and decision regarding the surgical approach Here difficult in the pre CT scan era This was further compounded by the complex anatomy of the Para pharyngeal space A case of Para pharyngeal lipoma is being presented because of its ratity and characteristic radiological features After confirmation of the diagnosis the tumor was excised via a transcertical approach

Serum Cytokine Profile in Patients with Chronic Rhinosinusitis with Nasal Polyposis Infected by Aspergillus flavus

Background Fungi, especially Aspergillus flavus, can cause chronic rhinosinusitis with nasal polyposis and modulate host innate immune components. The objective of this study was to examine the serum levels of T helper (Th) cell subset Th1, Th2, and Th17 cytokines and total IgE in patients having chronic rhinosinusitis with nasal polyposis and Aspergillus flavus infection. Methods A case-control study including 40 patients with chronic rhinosinusitis with nasal polyposis and 20 healthy controls was conducted. Aspergillus flavus infection was confirmed by standard potassium hydroxide (KOH) testing, culture, and PCR. Serum samples of all patients and controls were analyzed for various cytokines (interleukins [IL]-1β, IL-2, IL-4, IL-6, IL-17, IL-21, IL-27, TGF-β) and total IgE by ELISA. Data from patients with Aspergillus flavus infection and healthy volunteers were compared using the independent t-test and non-parametric Mann-Whitney U test. Results Aspergillus flavus infection was found in 31 (77.5%) patients with chronic rhinosinusitis with nasal polyposis. IL-1β, IL-17, IL-21, and TGF-β serum levels were significantly higher in these patients than in controls; however, IL-2, IL-4, IL-6, and IL-27 levels were lower. Compared with nine (22.5%) patients without Aspergillus flavus infection, IL-17 level was higher while IL-2 level was lower in patients with Aspergillus flavus infection. Total IgE was significantly higher in patients with Aspergillus flavus infection than in controls. Conclusions High levels of IL-17 and its regulatory cytokines in patients with chronic rhinosinusitis with nasal polyposis infected by Aspergillus flavus raise a concern about effective disease management and therapeutic recovery. Surgical removal of the nasal polyp being the chief management option, the choice of post-operative drugs may differ in eosinophilic vs. non-eosinophilic nasal polyposis. The prognosis is likely poor, warranting extended care.

Role of FNAC in the diagnosis of intraosseous jaw lesions.

Background FNAC of intraosseous jaw lesions has not been widely utilized for diagnosis due to rarity and diversity of these lesions, limited experience and lack of well established cytological features. Aim of the study was to determine the role of FNAC in the diagnosis of intraosseous jaw swellings. Material and Methods 42 patients underwent FNAC over a period of 7 years (2007-2013), of which 37 (88.1%) aspirates were diagnostic. Histopathology correlation was available in 33 cases and diagnostic accuracy of FNAC was calculated. Results Lesions were categorized into inflammatory 3, cysts/hamartomas 15 and neoplasms 19. Mandibular and maxillary involvement was seen in 21 and 16 patients respectively. Of these, benign cysts and malignant lesions were commonest, accounting for 27% lesions (10 cases) each. One case of cystic ameloblastoma was misdiagnosed as odontogenic cyst on cytology. Overall, sensitivity and specificity of FNAC were 94.7% and 100% respectively with a diagnostic accuracy of 97.3%. Definitive categorization of giant cell lesions, fibro-osseous lesions, odontogenic tumors and cystic lesions was not feasible on FNAC. Conclusions FNAC is a simple, safe and minimally invasive first line investigation which can render an accurate preoperative diagnosis of intraosseous jaw lesions, especially the malignant ones in the light of clinic-radiological correlation. Key words: Jaw swellings, intraosseous, FNAC.

Phenotypic and functional profile of Th17 and Treg cells in allergic fungal sinusitis

&NA; Interleukin‐17 producing T helper (Th17) and regulatory T cells (Treg) cells have been identified to play a critical role in atopic inflammation. However, conflicting reports on the role of Th17/Treg cells in allergic fungal rhinosinusitis (AFRS) patients of different ethnicities has mystified its pathogenesis. To better understand the pathophysiological mechanisms involved in AFRS, we conducted a prospective, analytical, case‐control study involving 40 confirmed immunocompetent AFRS patients and 20 healthy controls. The distribution of Th17 and Treg cells in PBMC, intracellular mRNA expression of retinoid orphan nuclear receptor (ROR&ggr;t) in Th17 and forkhead transcription factor (FoxP3) in Treg cells, and serum cytokine levels were investigated. Aspergillus flavus was identified from majority (85%) of patient tissue biopsies. Total serum IgE level along with cytokines IL‐17, IL‐21, IL‐1&bgr; and TGF‐&bgr; were comparatively elevated in AFRS. Nevertheless, IL‐2 and IL‐10 were reduced. Higher percentages of CD3+CD4+ T cells in AFRS with increased expression of CD161 and/or IL‐23R markers were observed. Though, lower percentages of CD4+CD25+ Treg cells with elevated expression of GITR were patent. Transcription factor ROR&ggr;t mRNA was upregulated, whereas FoxP3 mRNA was downregulated in AFRS patients. This inclination of Th17/Treg balance towards Th17, and the proposed role of Tregs on Th1 and Th2 cells in AFRS, directed us to conclude that Aspergillus infestation may lead to development of atopy and immunological dysbalance inciting a Th17 driven response, thereby, promoting aggravation of nasal polyposis. The observation may provide new insight into the molecular mechanisms leading to revision of the classical paradigm. HighlightsAspergillus flavus acts as the predominant etiological agent in allergic fungal rhinosinusitis in Indian population.Aspergillus infection leads to atopy and immunological dysbalance.Immunological dysbalance incites a Th17 driven response, thereby, promoting aggravation of nasal polyposis.