Abstract
A 64-year-old woman was admitted to a tertiary academic medical center with neutropenic fever of unknown etiology. Her medical history included asthma, IgG deficiency, and chronic rhinosinusitis. Her surgical history included endoscopic sinus surgery on 3 previous occasions. She was admitted to the medicine service and began broad-spectrum intravenous antibiotic therapy. The otolaryngology service was subsequently consulted regarding sinusitis being a possible infectious source. At the time of consultation, the patient complained of some moderate bilateral nasal congestion and a sore throat. Physical examination revealed a relatively well-appearing woman with mildly inflamed nasal mucosa and an injected posterior oropharynx. Fiberoptic nasal endoscopy and laryngoscopy performed at her bedside demonstrated several necrotic-appearing sinonasal mucosal lesions as well as a large ulcerative area on the right side of the epiglottis (Figure 1). At this time, she was profoundly neutropenic; however, blood cultures proved to be negative for microbial growth on several occasions. Given her immunocompromised state and a concern for an invasive fungal process, the decision was made to proceed immediately to the operating room for biopsy. View LargeDownload Operative endoscopy confirmed the findings of a pale, ulcerative lesion on the inferior surface of the right middle turbinate (Figure 2) and a necrotic plaquelike area involving the laryngeal surface of the epiglottis. Several intraoperative biopsy specimens of each lesion were sent for histopathologic evaluation and fungal staining. Histologic examination of the specimen from the middle turbinate showed respiratory mucosa with ulceration (Figure 3). There was necrosis of bone and fibrocartilage with depleted chondrocytes and bacterial invasion. A high-power view of the epiglottic biopsy specimen demonstrated vessel occlusion (Figure 4, asterisk) with perivascular cuffing by slender gram-negative rods (Figure 4, arrows), which were characteristic of Pseudomonas aeruginosa. Invasive fungal species were not evident in the specimens. View LargeDownload View LargeDownload View LargeDownload What is your diagnosis?
Journal
Archives of Otolaryngology - Head & Neck Surgery
– American Medical Association
Published: Dec 1, 2012
Keywords: biopsy,asthma,neutropenia,physical examination,ulcer,epiglottis,igg deficiency,intraoperative care,laryngoscopy,necrosis,nasal congestion,febrile neutropenia,surgical history,endoscopic sinus surgery,chronic sinusitis,endoscopic surgery,sore throat,blood culture,microbial growth,antibiotic therapy, intravenous,pallor,sinusitis,medical history,endoscopy of nose,osteonecrosis,fibrocartilage,larynx,respiratory mucosa,gram-negative bacillus,operating room,oropharynx,mucous membrane of nose,fiber optics,pseudomonas aeruginosa,academic medical centers,chondrocytes,immunocompromised host,otolaryngology,consultation
