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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 50-52

Aspergillosis of the palatine tonsil

1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Oral Microbiology and Pathology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India

Date of Submission13-Nov-2019
Date of Decision13-Jan-2021
Date of Acceptance14-Jan-2021
Date of Web Publication19-Feb-2021

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aiao.aiao_27_19

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Aspergillosis of the palatine tonsils is extremely rare. Immunodeficiency is an important risk factor for causing aspergillosis. The diagnosis of aspergillosis of the palatine tonsil may be overlooked in immunocompetent patients as it is often seen in immunocompromised. This lesion often mimics to the malignancy or premalignant lesion. Awareness of this lesion is required among the clinician for early treatment which depends on accurate diagnosis. Isolated aspergillosis of the palatine tonsils invariably responds well to antifungal therapy with the eradication of the risk factors. The definitive diagnosis is usually done by tissue biopsy and histopathological examination. Here, we reported a case of isolated aspergillosis of the palatine tonsil without involving the other parts of the pharynx and larynx and without any generalized immune deficits in a 42-year-old male. The patient was treated by antifungal agents.

Keywords: Aspergillosis, immunocompetence, palatine tonsil

How to cite this article:
Swain SK, Debta P. Aspergillosis of the palatine tonsil. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2020;4:50-2

How to cite this URL:
Swain SK, Debta P. Aspergillosis of the palatine tonsil. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2023 Mar 23];4:50-2. Available from: https://www.aiaohns.in/text.asp?2020/4/2/50/309786

  Introduction Top

Aspergillosis is an opportunistic fungal infection often affects the immunocompromised patient. Immunosuppression may be acquired or congenital. It may be seen in diabetes mellitus, AIDS, malignancy particularly hematological malignancy, and drug induced (e.g., steroids, antibiotics, and chemotherapeutic agents) or secondary to radiotherapy.[1] Aspergillus infections are often necrotizing, invasive, and associated with poor prognosis in case of immunocompromised patients.[2] In case of immunocompetent cases with Aspergillus infections, patients present with colonization rather than invasion needing no systemic antifungal treatment. Cases of isolated tonsillar aspergillosis are extremely rare clinical entity. The diagnosis of tonsillar aspergillosis is important as the presenting clinical symptoms are suspicious of tonsillar malignancy. When the palatine tonsils are affected by fungal infections, the patient complains of odynophagia and foreign body sensation in the throat which does not respond to antibiotics. This is a case report of the clinical manifestations, diagnosis, and treatment of isolated aspergillosis of palatine tonsils with infection of Aspergillus fumigatus of the palatine tonsil.

  Case Report Top

A 42-year-old male attended the outpatient department of otorhinolaryngology with complaints of pain and foreign body sensation in the throat for 1 month which was not improved by medications from local physicians. There was no significant history of dysphagia found. He had no history of any systemic disease except bronchial asthma for which taking inhalational corticosteroids (fluticasone 500 mcg twice daily) for 3 years. On examination of the oral cavity and oropharynx, a whitish pale patch was found over the left tonsil [Figure 1]. Indirect laryngoscopy revealed normal larynx and hypopharynx. The remainder of the otolaryngological examinations was within normal limits. Chest X-ray did not reveal any abnormality in the lungs. Routine blood and urine tests showed normal limits. A clinical diagnosis of the tonsillar keratosis was made and the patient was subjected to fiberoptic nasopharyngolaryngoscopy which revealed normal nasopharynx, oropharynx, hypopharynx, and larynx. A small amount of tissue was taken from the right tonsil and sent for histopathological and microbiological examination. The histopathological examination showed colonization of the spores and broad septate hyphae with acute angle branching. Potassium hydroxide staining revealed dichotomously branching septate hyaline fungal hyphae. Four days culture with Sabouraud dextrose agar showed fungal growth with bluish-green velvety and powered surface diagnosing the A. fumigatus [Figure 2]. The patient was treated with Itraconazole 100 mg per orally twice daily for 3 weeks with significant improvement of the symptoms. After 3 weeks of treatment with antifungal agents such as itraconazole, the patient showed complete disappearance of the whitish fungal lesion over the tonsil. The patient was cured and recovered to the asymptomatic state where palatine tonsils appear normal. The patient is on follow-up for the last 6 months with evidence of any recurrence.
Figure 1: Left tonsillar aspergillosis showing as a whitish patch

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Figure 2: Culture and microscopic view of the Aspergillus fumigatus; (a) View of the Aspergillus fumigatus on Sabouraud dextrose agar plate; (b) Reverse view of Aspergillus fumigatus on Sabouraud dextrose agar; (c) Microscopic image (×10) of Aspergillus fumigatus; (d) Microscopic image (×100) of Aspergillus fumigatus

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  Discussion Top

Isolated aspergillosis of the palatine tonsils is a rare opportunistic infection, especially in immunocompetent patients. Primary tonsillar aspergillosis is an extremely rare in clinical practice, although it is commonly found as a part of the systemic infection in an immunocompromised host. Aspergillosis is an inflammatory lesion caused by infection of fungi of the genus Aspergillus. Infections of Aspergillus are usually resulting of contagious spread from the nose and paranasal sinuses.[3] Diabetes mellitus, advanced age, prolonged steroid treatment, chronic obstructive pulmonary diseases, low CD4 lymphocyte cells, leukemia, lymphoma, HIV infection, etc., can cause immunocompromised conditions which are often considered as etiological factors.[4] But in immunocompetent patients, there are no such findings for explaining the development of this primary fungal infection. Aspergillus species are spore-forming fungi along with dichotomous branching pattern. These fungi are often seen in humid areas, soil, agricultural environment, and decaying materials.[5] Aspergillus species which affect the human being are Aspergillus fumigatus, Aspergillus niger, Aspergillus flavus, and Aspergillus oxyzae. Aspergillus fumigatus is the most common species seen in immunocompromised patients.[2] There are three varieties of Aspergillus such as noninvasive, destructive, and invasive. The noninvasive and destructive variety usually affects immunocompromised persons.[6] Invasive types of Aspergillus infections are usually aggressive and often affect immunocompromised patients. This invasive type is usually associated with high morbidity and mortality.[7] The tonsillar localization of the aspergillosis is extremely rare and is often secondary to severe aspergillosis of the tracheobronchial airway. Interestingly, none of the 98 patients diagnosed with aspergillosis studied by Young et al. had isolated tonsillar involvement.[8]

Aspergillus is a saprophytic fungus inhibiting in soil. Thus, a healthy individual engaged in farming and carpentry occupation may be an etiological factor for causing primary aspergillosis of the upper airway or palatine tonsil.[9] Although the history of oral sex is a predisposing factor for causing the localized aspergillosis, fellatio may be a highly suspected predisposing factor. Fellatio may cause local mucosal membrane injury by repeated friction and leads to primary Fellatio may cause local mucosal membrane injury in the oropharynx (palatine tonsils) by repeated friction and leads to primary Aspergillus infection of the palatine tonsils in an immunocompetent person.[10] Perhaps, Aspergillosis is the most commonly encountered as a saprophytic growth in the external auditory canal. It is also the most common fungal infection of the paranasal sinuses.[11] In our case, the Aspergillus infection of the tonsil was of noninvasive type. There was no evidence of adjacent tissue destruction, no evidence of necrosis, and blood vessel invasion. To our knowledge, there was no documentation of primary Aspergillus infection of the palatine tonsil in an adult immunocompetent person.

At present, the demographic data showed shifting of incidence of primary fungal infections at the oropharynx or larynx from old to young and male to female which may be explained by the increased practice of oral sex.[12] However, more evidence or data are still required to prove such relations. Now, more attention is needed to oral sex history, although this is a rare and rapidly increasing diagnosed lesion in the human being.

Isolated Aspergillus infection of the palatine tonsil is an extremely rare disease in immunocompetent persons as in our case. There are certain iatrogenic factors like radiotherapy, corticosteroid inhaler use, and laser treatment that may predispose to the localized forms of aspergillosis.[13] The important possible risk factor in our case includes the practice of inhalation of corticosteroids which may transmit direct transmission of fungus to the palatine tonsils. The clinical presentation in this case is odynophagia and foreign body sensation in the throat. With unusual clinical features and oropharyngeal examination findings, this lesion often confuses with malignancy or premalignant lesion which is usually considered as primary differential diagnosis. Equivocal clinical presentations and histopathological evidence of acanthosis and pseudoepitheliomatous hyperplasia can cause misdiagnosis for malignancy or premalignant lesions.

The Aspergillus hyphae appear basophilic with eosin and hematoxylin stain. However, periodic Gomori methenamine silver stain, reticular silver impregnation method, periodic acid-Schiff, and hematoxylin stain provide a better morphological appearance of the hyphae. Aspergillus is confirmed by circular, uniform mycelium on section, septate hyphae, and sometimes folds with dichotomous branching. Histopathological examination is confirmatory. In our case, tonsillar tissue from the palatine tonsil was sent for the histopathological study which confirmed the Aspergillus fungi.

Treatment of the aspergillosis is often problematic. Removal of the palatine tonsils of this case facilitates the relief of the symptoms. But without doing tonsillectomy, proper antifungal treatment will cure the disease. Early diagnosis is often crucial to prevent further transmission of the disease. Treating with antifungal agents is helpful in aspergillosis of the patients with normal immune systems, but their value in managing immunocompromised patients is uncertain. Amphotericin B is still considered as the first line of treatment for this infection but is associated with severe systemic side effects. The antifungal agent like itraconazole is a promising agent for this infection.[14] Itraconazole in the liquid formulation may produce more reliable and constant levels. Certain drugs such as rifampicin, cyclosporine, phenytoin, and other drugs may create interaction with itraconazole. In our case, itraconazole was found to be an effective antifungal agent with encouraging outcome. The treatment should also cover to eliminate any predisposing factors, as failure to do this, may lead to persistence or recurrence of this condition.

  Conclusion Top

Isolated aspergillosis of the palatine tonsils is an extremely rare opportunistic infection, particularly in an immunocompetent host. This rare fungal infection of the palatine tonsils must be kept in mind during examining the patients with whitish patch over the tonsils. The clinical presentation like whitish patch and pain in the throat is usually masquerading the other possible pathologies which make early diagnosis. Inhalational corticosteroids are often used by people as over the counter drugs without proper advice by physicians. Hence, this rare and serious complication of inhalational corticosteroid must be kept in mind before rampant use of the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Florent M, Ajchenbaum-Cymbalista F, Amy C, Rio B, Molina T, Audouin J, et al. Dysphonia and dysphagia as primary manifestations of invasive aspergillosis. Eur J Clin Microbiol Infect Dis 2001;20:441-2.  Back to cited text no. 1
Nahar S, Pillai AK, Kumar JA, Goyal N, Singh SK. Orbital invasive aspergillosis – A rare fungal infection of eye. Int J Sci Study 2013;1:150-4.  Back to cited text no. 2
Levin LA, Avery R, Shore JW, Woog JJ, Baker AS. The spectrum of orbital aspergillosis: A clinicopathological review. Surv Ophthalmol 1996;41:142-54.  Back to cited text no. 3
Ran Y, Yang B, Liu S, Dai Y, Pang Z, Fan J, et al. Primary vocal cord aspergillosis caused by Aspergillus fumigatus and molecular identification of the isolate. Med Mycol 2008;46:475-9.  Back to cited text no. 4
Aggarwal E, Mulay K, Menon V, Sundar G, Honavar SG, Sharma M. Isolated orbital aspergillosis in immunocompetent patients: A multicenter study. Am J Ophthalmol 2016;165:125-32.  Back to cited text no. 5
Mody KH, Ali MJ, Vemuganti GK, Nalamada S, Naik MN, Honavar SG. Orbital aspergillosis in immunocompetent patients. Br J Ophthalmol 2014;98:1379-84.  Back to cited text no. 6
Myoken Y, Sugata T, Tai Chi K, Fujihara M. Pathologic features of invasive oral. J Oral Maxillofac Surg 1996;56:263-70.  Back to cited text no. 7
Young RC, Bennett JE, Vogel CL, Carbone PP, DeVita VT. Aspergillosis. The spectrum of the disease in 98 patients. Medicine (Baltimore) 1970;49:147-73.  Back to cited text no. 8
Nong D, Nong H, Li J, Huang G, Chen Z. Aspergillosis of the larynx: A report of 8 cases. Chin Med J (Engl) 1997;110:734-6.  Back to cited text no. 9
Ran Y, Lu Y, Cao L, Li C, Dai Y, Yang H, et al. Primary laryngeal aspergillosis related to oral sex? A case report and review of the literature. Med Mycol Case Rep 2012;2:1-3.  Back to cited text no. 10
Doloi PK, Baruah DK, Goswami SC, Pathak GK. Primary aspergillosis of the larynx: A case report. Indian J Otolaryngol Head Neck Surg 2014;66:326-8.  Back to cited text no. 11
Saini R, Saini S, Sharma S. Oral sex, oral health and orogenital infections. J Glob Infect Dis 2010;2:57-62.  Back to cited text no. 12
Fairfax AJ, David V, Douce G. Laryngeal aspergillosis following high dose inhaled fluticasone therapy for asthma. Thorax 1999;54:860-1.  Back to cited text no. 13
Swain SK, Sahu MC, Baisakh MR. Mucormycosis of the head and neck. Apollo Med 2018;15:6.  Back to cited text no. 14
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  [Figure 1], [Figure 2]

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