A 69-year-old lady with a past medical history of diabetes, hypertension, stage-4 chronic kidney disease, and systolic heart failure presented with a rapidly growing nasal mass over a period of 4 months that started out as a pimple which ruptured and started to grow from the nasal bridge up to the tip of nose along columella interiorly into her left nasal cavity. She denied pain, fever, cough, dyspnea, gastrointestinal symptoms, chest pain, visual abnormalities, hematuria, or recent travel. During her admission 3 months back for an episode of decompensated heart failure, the mass was noted to be small, so she was referred to an ENT clinic where a superficial biopsy was done. The histopathology result was nondiagnostic showing squamous mucosa with pseudoepitheliomatous hyperplasia along with acute and chronic inflammatory changes. After this biopsy, the mass enlarged rapidly causing nasal congestion and runny nose, and the patient was admitted to the hospital for further evaluation of the mass. Patient was afebrile throughout admission, and her hemodynamics were stable. Examination showed a large exophytic left nasal mass involving the nasal bridge, columella, ala, philtrum with crusting, areas of hemorrhage, and a few pustules. Left nostril was almost completely occluded during the end of her hospital admission. There was also a 2 cm mobile mildly tender left submandibular lymphadenopathy. Lung exam was unremarkable (Figures 1 and 2).
CT neck confirmed the examination findings and also demonstrated inferior nasal turbinate connection of the mass, while CT of the chest showed bilateral pulmonary nodules, bilateral fibrotic opacities, pleural thickening of bilateral pleura, fibrocystic changes of the right lower lobe of the lung, and posterior mediastinal and probable hilar lymphadenopathy. A repeat biopsy of the nasal lesion was again inconclusive demonstrating nonspecific chronic inflammation, fibrosis, and suppurative necrosis. Special stains were negative for fungal infections and acid-fast bacilli. During this time, the differential diagnoses were granulomatous and inflammatory diseases such as sarcoidosis, small vessel vasculitis viz. granulomatosis with polyangiitis, tuberculosis, atypical fungal infections such as rhinosporidiosis, histoplasmosis, blastomycosis, and malignancy; therefore, multidisciplinary discussion was done involving pulmonology, rheumatology, ENT, infectious disease, nephrology, dermatology, and cardiology. On laboratory evaluation, she was noted to have chronic stable anemia with normal white counts, and liver profile was normal except for mild hypoalbuminemia. Her autoimmune panel came back with positive antinuclear antibody (ANA) (<1 : 160) and myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA/p-ANCA) with a titer of 7.6 (ref.: <1). Anti-dsDNA, anti-Smith-Ab, anti-RNP, anti-SSA, and anti-SSB were negative, and C3 and C4 were within normal limits. ESR and CRP were elevated at 103 mm/hr and 8.6 mg/dl, respectively. Her previous urinalysis had few RBC casts, but recent urine was bland; therefore, renal biopsy was deferred. Three sputa smears for acid-fast bacilli, HIV and cryptococcal antigen, and hepatitis A, B, and C serologies were negative. Urine histoplasma and Blastomyces antigen were sent, but results are pending. The left nostril was packed with Merocel impregnated in dexamethasone, and the patient was covered with intravenous ampicillin-sulbactam for possible bacterial superinfection. Bronchoscopy with a biopsy of accessible hilar lymph node was considered, but patient refused the procedure; so, it was withheld. Therefore, a repeat biopsy of the nasal mass and submandibular lymph node was done, and the specimen was sent for special fungal stains, AFB cultures, and histopathology.
The patient was discharged with symptomatic care after the repeat punch biopsy of the nose and cervical lymph node with pending results. Urine antigen came back positive for both Histoplasma and Blastomyces antigens, and the third biopsy demonstrated noncaseating granulomatous inflammation with fungal elements that, on staining with periodic acid-Schiff (PAS) and Grocott-Gomori methenamine silver nitrate (GMS) stains, it showed large round to oval yeasts with double contour and single broad-based buds consistent with blastomycosis. Putting together her clinical picture and laboratory findings, she was diagnosed to have disseminated blastomycosis.
The patient is being readmitted for systemic antifungal therapy.