Nasal obstruction and bone erosion caused by Drechslera hawaiiensis

G.F., a 15-year-old male presented to an E.N.T. surgeon on 16.1.76 with a six-month history of predominantly left-sided nasal obstruction and a two-week history of left proptosis with diplopia. Periorbital oedema was present on the involved side. The patient, a keen swimmer, was not acutely ill. The clinical findings were those of a sinusitis with polyp formation on the left. X-ray investigation revealed an opaque left antrum and ethmoids, with mucosal thickening in the other sinuses. The patient was subjected to a left antrostomy and partial ethmoidectomy for the total removal of polypoidal and granulation tissue. At operation three distinct types of material were found, namely: polypi-granulation tissue; green gelatinous material resembling inspissated pus; and nests of a friable brown substance. All of these were sent for histological analysis and were found to be mainly mucus with degenerate inflammatory cells. The maxillary mucosa was a squamous epithelium overlying a stroma in which there were numerous eosinophils and occasional plasma cells. The nasal mucosa was respiratory epithelium with a chronically inflamed stroma. Fungal hyphae resembling mucormycosis were noted but could not be positively identified. The aetiological significance of these fungal elements was uncertain and had to remain suspect until further proof could be obtained. In view of the unusual findings the patient was referred to the E.N.T. Department of the Johannesburg Hospital, on 2 February 1976, for further investigation. Tests which included F.B.C., E.S.R., U. & E., plasma proteins; acid phosphatase; creatinine and blood sugar assessments were within normal limits. A large intranasal antrostomy was evident on clinical examination. Theie was no sign of any residual abnormal tissue. In view of this latter observation and the uncertain significance of the fungal hyphae observed, antifungal treatment was not given. The patient was discharged to careful outpatient follow-up. The proptosis did not improve and the left nostril became obstructed again. The diplopia which had disappeared after the initial operation reappeared transiently for two days.