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Case of the Month - April 2019

Dr D Steyn, Dr S Potgieter, Dr E Glover
Universitas Academic Hospital

Case Presentation:
A 56yr old female from Bloemfontein was referred to the Department of ENT at Universitas Academic Hospital in November 2018 with a 6 month history of dysphagia, odynophagia, dysphonia and otalgia. Upon presentation she was completely unable to swallow solids and semi-solids.

She had been started on empirical TB treatment in February of the same year after seeking medical attention at a local hospital for marked weight loss and generalized lymphadenopathy. Sputum at that stage was TB geneXpert negative but biopsy of a supraclavicular lymph node showed granulomatous inflammation with caseous necrosis and a histological diagnosis of TB was thought compatible. Unfortunately no tissue samples were sent to the TB laboratory for microbiological confirmation. Despite 9 months of TB treatment she had progressive weight loss, dropping 4 dress sizes. She had no known chronic diseases and was on no chronic medication. She had no significant surgical history and had never smoked or used alcohol. She was born in a rural village in the Eastern Cape and had spent her most of her life there. Her family had moved her to Bloemfontein in the previous year when she had become too unwell to stay alone. She had no travel history and no occupational exposure

Upon examination she was noted to be cachectic with conjunctival pallor. The previously reported generalized lymphadenopathy was not present. She had hoarseness of voice and stridor. She was not able to swallow even saliva due to a large mass at the base of her tongue. Apart from the stridor, cardiopulmonary exam was normal as was abdominal examination.

Upon laryngoscopy she was found to have a large mass lesion extending from the right tongue base to involve the epiglottis, posterior pharyngeal wall and larynx. A CT scan of her head and neck was requested and is shown below.

Blood workup showed a decreased Hb with red cell indices in keeping with anaemia of chronic disease. Marked hypokalaemia and hypoalbuminaemia was present and thought to be due to malnutrition associated with long standing difficulty in swallowing solids. UEC and LFT were further normal. HIV ELISA was negative. The patient was admitted to the ward and prepared for theatre the following day where she underwent biopsy of the lesion and tracheostomy insertion for imminent airway obstruction.

Based on the findings at laryngoscopy as well as the CT features the only differential diagnosis considered was a base of tongue malignancy.

Biopsy samples were sent for histological and microbiological examination. Initial cultures grew only oral flora with negative mycobacterial and fungal cultures. Histology of the lesion was reported to be in keeping with Rhinoscleroma. Mycobacterial and fungal stains were negative as was tissue TB geneXpert. No evidence of malignancy was found. We requested a repeat biopsy, which again excluded malignancy, mycobacterial and fungal infection and was reported as being histologically in keeping with Rhinoscleroma.

Question 1: What is Rhinoscleroma?

Continue to Answer 1