Journal of Medical & Veterinary Mycology 1996, 34, 215-218
Accepted 4 January 1996
Case report
Maxillary sinusitis caused by Ascotricha chartarum Berk.
(anamorph Dicyma ampullifera Boul.): a new phaeoid
opportunistic human pathogen
S. M. SINGH*, J. N A I D U * , S. JAIN t, S. R. N A W A N G E * & M. K. D H I N D S A *
*Medical Microbiology Laboratory, Department of Biological Science, Rani Durgavati University,Jabalpur 482 00 I; and
tPrasan ENT Hospital, 569, Marhatal Jabalpur 482 002, India
The first human infection caused by Ascotricha chartarum of the maxillary sinus is
described. The patient, a 35-year-old woman, developed a hard bony swelling on the
right cheek. Her maxillary X-ray showed complete opacity of the right maxillary
antrum with a shadow of erosion. C.T. scan revealed a radio opaque mass having
vacuolated appearance in the antrum. The debris removed from the antrum contained
phaeoid fungal elements. At places, softening of the bone was observed. The
mucoperiosteum exhibited acute inflammatory reaction and invasion by the pathogen.
The pale brown to subhyaline fungal elements in biopsy tissue grew Ascotricha
chartarum, a phaeoid ascomycetous fungus in culture. The patient had a smooth
recovery when treated with betadine lavage and itraconazole after surgical
intervention.
Keywords Ascotricha chartarum, maxillary sinusitis.
Introduction
Infections caused by melanoid fungi are emerging in large
numbers across the globe as evidenced by the appearance
of new cases in the literature. In 1974, when Ajello et al.
[1] proposed the disease name phaeohyphomycosis for
such infections, they listed nine fungi as causative agents.
In 1992, however, Kwon Chung & Bennett [2] listed 59
species classified in 28 genera of melanoid fungi documented both mycologically and histopathologically.
Recently, Matsumoto et al. [3] listed 57 genera and 101
species of phaeoid pathogens that have been confirmed as
agents of phaeohyphomycosis.
Several cases of sinusitis caused by phaeoid fungi
have been reported in the literature [4]. Among them,
sinusitis caused by Bipolaris spicifera [5,6], B. australiensis
[7], B. hawaiiensis [4,6,8] Exserohilum rostratum [5],
E. mcginnisii [9] and Curvularia lunata [10] Alternaria
Correspondence: Prof. S.M. Singh, Department of Biological Science, Medical Microbiology Laboratory, R.D. University, Jabalpur
482 001, India.
© 1996 ISHAM
species [11,12] and Cladosporium trichoides [13] are worth
mentioning.
In this paper we describe the first human case of
maxillary sinusitis caused by the melanoid ascomycetous fungus Ascotricha chartarum and its successful
treatment.
Case report
A 35-year-old female farmer-cum-housewife and resident
of Narsinghpur (M.P.), India, presented at the clinic of
one of the authors (S.J.) on 28 December 1993 with the
complaint of swelling over the right cheek which gradually increased in size during the previous 3 months
(Fig. 1). The swelling resulted after an injury to the face.
A few days after the incident, mucopurulent nasal discharge was seen occasionally. Once she also had bloodstained nasal discharge. There was no history of frank
epistaxis, nasal obstruction, diplopia, proptosis or loosening of the teeth. She was examined by a local doctor who
made a presumptive diagnosis of carcinoma of the maxillary antrum (right). To confirm the diagnosis she was
Singhet al.
!
PO
Fig, 2 CT scan of the maxilla showing radio-opaque mass in the
Fig. 1 Clinical aspect of maxillary sinusitis.
referred to us. On detailed examination, she was found to
have a hard bony swelling, 4 cm x 3'5 cm in size on the
right side of the maxilla that completely obliterated
the canine fossa. Mild tenderness could be elicited over
the swelling without any sign of inflammation. Both the
nostrils were without any displacement of the lateral wall.
The hard palate was depressed on the right side; no
erosion could be seen. The orbital floor was normal
without proptosis or restricted eye movements. Posterior
rhinoscopy was normal, as were throat and ears. X-ray of
paranasal sinuses (Water's view) showed complete opacity
of right maxillary antrum with a doubtful shadow of
erosion. The patient was anaemic but had no unremarkable past medical history. Fine needle aspiration cytology
was performed which revealed only acute inflammatory
cells.
A computed tomographic (CT) scan revealed the presence of a radio opaque mass having a vacuolated appearance completely filling the right maxillary antrum (Fig. 2).
The floor of the antrum was depressed and the anterolateral wall inflated. No clear bony erosion was seen.
Multiple shadows of air bubbles in the mass aroused
suspicion of a fungal mass. To confirm the diagnosis a
biopsy was obtained using the Cald-Well-Luc procedure.
On opening, the antrum was found to be filled with grey
coloured, cheesy material without any evidence of tumour
mass. All the debris was removed with a wide-bore
suction cannula and the mucoperiosteum curetted. At
some sites, softening of the bone was observed but no
clear erosion was visible. A large intranasal antrostomy
was made and during the postoperative period regular
betadine lavage was given for 15 days along with antifungal treatment employing 200 mg itraconazole per day.
This approach resulted in a smooth recovery for the
patient.
antrum.
Materials and methods
A part of the antrum content along with curetted mucoperiosteum obtained after surgical excision was fixed in
10% formalin, embedded in paraffin, sectioned and
stained with Gomori's methenamine silver nitrate (GMS),
cotton blue and haematoxylin and eosin (H&E). Some
unstained sections were also prepared to evaluate the
natural colour of the fungus in vivo. A portion of
the sample was homogenized and smears were obtained
with Gram stain. Biopsy material was aseptically inoculated onto: (i) Nutrient agar medium (Himedia, Bombay)
without antibiotics and (ii) Sabouraud glucose agar
(SGA) slants containing 0"05/~g m l - ~ chloramphenicol.
The slants were incubated at 28 °C for 2 weeks. A part of
the clinical material was examined microscopically in 10%
KOH. Thermotolerance and morphological studies were
carried out on SGA medium at 28, 37, 40 and 43 °C.
Results
Histological sections of the biopsy specimen consisting of
the antrum debris and surrounding mucoperiosteum
revealed the presence of subhyaline to olivaceous, loose
mass of unusually-shaped fungal hyphae. The fungus
was subhyaline to light brown and consisted of short or
long, thin to thick, septate, finely verrucose branched
or unbranched hyphal elements that were sometimes
aggregated, scattered, or as single spherical cells. Sections
stained with H&E revealed granulomatous cellular infiltration, chiefly consisting of lymphocytes and many
congested vessels supported by fibrous stroma. In a
Gram-stained smear, Charcot Leyden crystals and few
epithelial cells were observed. The mucoperiosteum
appeared soft and uneven and compatible fungal hyphae
were seen invading the tissue. Homogenized clinical
© 1996 ISHAM, Journal of Medical & Veterinary Mycology 34, 215-218
A new phaeoidpathogen ~ ] ~
Fig. 3 Micromorphologyof conidiogenous cells and eonidia of
Dicyma ampullifera; teleomorph A. chartarum. ( x 1400.)
specimens were also examined in 10% KOH. Brown,
septate, thin to thick walled mycelial elements were
observed. Ascotricha chartarum was isolated from the
clinical sample on Sabouraud glucose agar with chloramphenicol. On nutrient agar without antibiotic, growth of
non-haemolytic streptococci was seen along with the
growth of A. chartarum. Specific identification was
confirmed by Professor J. Guarro, Department of Microbiology, Faculty of Medicine, University of Rovira,
Virgili, Spain.
Colonies of A. chartarum on SGA at 28 °C after 7 days
were 12 mm in diameter, initially dull white turning
blackish, felt-like, glabrous, slightly raised in the centre,
and a reverse without pigmentation. At 37 °C after 7 days,
colonies measured 10-12mm, and were dull white,
glabrous and raised in the centre. At 40 °C the colonies
were similar to those grown at 37 °C, about 5 mm in
diameter after 7 days. The fungus grew up to 43 °C.
Conidiophores either developed independently or arose
from terminal hairs. They were olivaceous brown to black
brown becoming pale brown or hyaline toward their
apices, ampullate, septate, up to 3.5-5.5~m in diameter.
Conidia arose irregularly as clusters on the conidiophores
and were globose to ellipsoidal, walls finely verrucose,
hyaline when young becoming fuscous to light brown with
age, 4'5-5 x 2-3-5/~m (Fig. 3). The anamorph is Dicyma
ampullifera Boul.
Perithecia, dark brown to black, ostiolate, globose to
subglobose 100 250 x 120-240/tin, neck short cylindrical;
terminal hairs erect, rigid septate, often dichotomously
branched, geniculate, olivaceous dark brown to black
4-5 6-5/~m at the base, tapering towards the apex, short,
sterile, hyaline to pale fuscous branches between dichotomies and at geniculate nodes. Lateral and terminal hairs
abundant and similar in morphology, 3 4 / ~ m at the base
(Fig. 4); asci linear, cylindrical, thin-walled, evanescent,
8 spored, 65 70x 8-11/zm; ascospores uniseriate,
© 1996 ISHAM, Journal of Medical & Veterinary Mycology 34, 215-218
Fig. 4 Perithecia and setae of A. chartarum. ( x 1500
Fig. 5 Ascospores of A. chartarum. ( x 1200.)
dark brown to black when mature discoid, measuring [7]
7.5 9 x 6 - 8 x 5-6¢tm with a distinct, equatorial furrow
(Fig. 5). The culture has been deposited in the CBScollection as Ascotricha chartarum (Berk)=CBS 245.96.
Discussion
Four forms of fungal sinusitis have been described in the
literature [6,14]. These are mycetoma, invasive, indolent
and allergic fungal sinusitis. Sinus mycetoma is unilateral
with no bony destruction. Pathologically in such cases
there is closely packed tangled mass of fungal hyphae
without allergic mucin. The invasive form can be slowly
progressive or rapidly aggressive. Initially, in such cases,
one sinus is involved with soft tissue necrosis and granulomatous reaction that later leads to extensive bony
destruction. Indolent fungal sinusitis is a chronic, unilateral sinusitis usually seen in immunocompetent
patients. Histopathologically, these cases show chronic
fibrosing granulomatous inflammation with multinucleated giant cells. Allergic fungal sinusitis occurs
in atopic individuals, affects multiple sinuses, is chronic in
nature and demonstrates no histological evidence of tissue
Singh et al.
invasion. Histologically, allergic mucin is present and
aggregates of inflammatory cells, mostly eosinophils, and
numerous Charcot-Leyden crystals are seen.
In comparison, our case best meets the clinical and
histopathological features of indolent and allergic fungal
sinusitis. By definition, there is no tissue invasion by fungi
in this type. In the present case, however, slowly progressing invasion by A. chartarum of the surrounding mucoperiosteum was observed. The same was confirmed by
histopathology which exhibited the presence of compatible fungal elements and inflammatory cells in the tissues.
Fine needle aspiration cytology also confirmed the
presence of inflammatory cells.
A. chartarum Berk (Anam. Dicyma ampullifera Boul.)
has been isolated from paper, linoleum, plaster, cardboard,
cork, skin, soil, plant material and lignum from several
countries including India [15]. This is the first report of
its occurrence as an opportunistic human pathogen causing maxillary sinusitis. The pathogenic potential of A.
chartarum is supported by its ability to grow at 37 and 40 °C.
Sinusitis caused by dematiaceous fungi are often reported to
be associated with debilitating diseases [15,16]. Our patient
had no such disease and was apparently immunocompetent.
Regarding the portal of entry of the pathogen from the
environment, we believe that it may be through natural ostia
and the predisposing factor in this case was the trauma
received on the maxilla by the patient.
The initial response to surgery, such as ethmoidectomy
or the Caldwell Luc procedure, is excellent in all these
entities [17], but symptoms may reappear after some time
if the surgeon does not aggressively clean out all the
infected areas. In our patient, using the Caldwell-Luc
procedure, the maxillary antrum was aggressively cleaned
and in the postoperative period betadine lavage was given
along with itraconazole (100 m g capsule twice a day for 15
days). The patient showed smooth recovery and the posttreatment period was uneventful. In such cases, treatment
with IV amphotericin B, oral ketoconazole or itraconazole
have all been advocated; however, of the three drugs,
itraconazole appears to be the most promising [18]. The
present finding corroborates the same.
The significance of dematiaceous fungi as agents of
human diseases is genuine [19]. Clinicians and microbiologists may encounter A. chartarum and similar fungi,
particularly in countries such as India where they are
known to exist.
Acknowledgements
We thank the Head, Department of Biological Sciences,
R.D. University, Jabalpur for providing laboratory
facilities; Dr J. Guarro, Department of Microbiology,
Faculty of Medicine, University of Rovira I Virgili, Spain,
for confirming the specific identification of the fungus and
to Janssen Pharmaceutical, Belgium, for supplying the
itraconazole for treatment.
References
1 Ajello L, Georg LK, Steigbigel RT, Wang CJK. A case of
phaeohyphomycosis caused by a new species of Phialophora.
Mycologia 1974; 66: 490-8.
2 Kwon-Chung K J, Bennett JE. Medical Mycology. Philadelphia,
PA: Lea & Febiger, 1992.
3 Matsumoto T, Ajello L, Matsuda T, Szaniszlo PJ, Walsh TJ.
Developments in hyalohyphomycosis and phaeohyphomycosis.
J Med Vet Mycol 1994; 32 suppl. 1" 32949.
4 Koshi G, Anandi V, Kurien M, et al. Nasal phaeohyphomycosis
caused by Bipolaris hawaiiensis. J Med Vet Mycol 1987; 25:
397402.
5 Adams RD, Paquin ML, Petersen EA, et al. Phaeohyphomycosis
caused by the fungal genera Bipolaris and Exserahilum. Medicine
1986; 65: 203-17.
6 Gourley DS, Whisman BA, Jorgensen NL, Martin ME, Reid MJ.
Allergic Bipolaris sinusitis: clinical and immunopathologic
characteristics. J Alter Ctin tmmunol 1990; 85: 583-91.
7 Harpster WH, Gonzalez C, Opal SM. Pansinusitis caused by the
fungus Dreschslera. Otolaryngol Head Neck Surg 1985; 93" 683-5.
8 Fuste F J, Ajello L, Threlkeld R, Henry JE. Drechslera hawaiiensis: causative agent of a fatal meningo-encephalitis. Sabouraudia
1973; 11" 59 63.
9 Padhye AA, Ajello L, Wieden MA, Steinbronn KK. Phaeohyphomycosis of the nasal sinuses caused by a new species of
Exserahilum. J Clin Microbial 1986; 24: 245-9.
10 Bartynski JM, McCaffrey TV, Frigas E. Allergic fungal sinusitis
secondary to dematiaceous fungi: Curvularia and Alternaria.
Otolaryngol Head Neck Surg 1990; 103: 32-9.
11 Murtagh J, Smith JW, Mackowiak PA. Alternaria osteomyelitis;
eight years of recurring disease requiring cyclic courses of
amphotericin B for cure. Am J Med Sci 1987; 293: 399402.
12 Shugar MA, Montogomery WW, Hyslop NE. Alternaria
sinusitis. Ann Otol, Rhinol Laryngol 1981; 90 (3 Pt 1): 2514.
13 Brown JW, Nadell J, Sanders CV, Sardenga L. Brain abscess
caused by Cladosporium trichoides (Bantianum). A case with
paranasal sinus involvement. South Med J 1976; 69:1519 21.
14 Gotdstein MF, Atkins PC, Cogan FC, et at. Allergic Aspergillus
sinusitis. JAller Clin lmmunol 1985; 76: 515-24.
15 Hawksworth DL. A revision of the genus Ascotricha Berk.
Mycological paper no. 1 2 6 . Commonwealth Mycological
Institute, Kew, Surrey, England, 1971, pp. 1-9.
16 Body BA, Sabio H, Oneson RH, et al. Alternaria infection in a
patient with acute lymphocytic leukemia. Pediatr Infect Dis" J
1987; 6:418 20.
17 Young CN, Swart JG, Ackermann D, Davidge-Pitts K. Nasal
obstruction and bone erosion caused by Drechslera hawaiiensis.
J Laryngol Otol 1978; 92" 13743.
18 Sharkey PK, Graybill JR, Rinaldi MG, et al. Itraconazole
treatment of phaeohyphomycosis. J Am Acad Dermatol 1990; 23
(3 Pt 2): 577 86.
19 McGinnis MR, Rinaldi MG, Winn RE. Emerging agents of
phaeohyphomycosis: pathogenic species of Bipolaris and
Exserohilum. J Clin Microbial 1986; 24: 250-9.
© 1996 ISHAM, Journal of Medical & Veterinary Mycology 34, 215-218