Photo Quiz: A Bag of Marbles in the Nose

A 51-year-old man presented with nasal congestion, pharyngeal discomfort, and chronic cough which had appeared several months previously. He was immunocompetent, and the only significant history was a moderate factor V deficiency. The patient had no fever, headache, cacosmia, or nasal obstruction. A cranial CT scan showed right maxillary sinusitis potentially associated with a suspected fungus ball surrounded by an inflammatory reaction (Fig. 1A). The nasofibroscopy did not find any particular abnormality. The patient underwent right endoscopic maxillary antrostomy with extraction of the fungus ball. Intraoperative specimens were sent for microbiological and histopathological investigations.

FIG 1.

(A) Axial section of a cranial CT scan highlighting a fungus ball (red arrow) in the right maxillary sinus with inflammatory reaction at the periphery. (B and C) Histological examination of intraoperative specimen without staining (B) and after Fontana-Masson staining (C). (D) Lactophenol cotton blue staining performed on the culture showed septate hyaline hyphae (2 to 4 μm in diameter) from which solitary annelloconidia emerged. Bars, 20 μm.

Histological examinations without staining (Fig. 1B) and then hematoxylin-eosin-saffron (HES) and Fontana-Masson staining (Fig. 1C) were performed. Samples were also cultured on Sabouraud medium at 37°C. Cottony and woolly colonies, white at first and then brownish black, grew after 3 days. Lactophenol cotton blue staining performed on the culture showed hyaline septate hyphae ending in truncated conidia (Fig. 1D).