Infestation of the lacrimal sac by Rhinosporidium seeberi: A clinicopathological case report
A 25-year-old North-Indian male presented to our center with history of recurrent painful swelling below the right lower lid for the past 1 year with associated watering. He also gave history of chronic sinusitis for the past 10 years. There was no history of purulent or serosanguineous discharge. He was diagnosed elsewhere as a case of chronic dacryocystitis of the right lacrimal sac and treated with systemic antibiotics with no resolution in symptoms. A computerized tomography (CT) scan was done 1 year back which reported a small oval swelling in the right medial canthal region with deviated nasal septum, bilateral small maxillary sinus polyps, and concha bullosa.\nOn examination, vision was 6/6 N6 in both eyes. Anterior and posterior segment examinations of both eyes revealed normal findings. There was fullness of the right lower lid with erythema, induration, and tenderness. Regurgitation on pressure on the lacrimal sac (ROPLAS) was negative and syringing showed the lacrimal drainage system to be bilaterally patent. A clinical diagnosis of right partial nasolacrimal duct obstruction with preseptal cellulitis was made. An otolaryngology opinion was sought. Nasal endoscopic evaluation revealed a deviated nasal septum to the left with giant concha bullosa with tenderness and congestion over the lacrimal sac area. The patient was started on systemic antibiotic and nonsteroidal anti-inflammatory agents. However, there was no clinical improvement even after 1 month. Since his clinical features were suggestive of idiopathic orbital inflammatory disease (IOID), a trial of systemic steroids was given. The patient reported symptomatic relief after 2 days.\nMeanwhile, the patient underwent right conchoplasty under general anesthesia by the otolaryngologist based on the history of recurrent episodes of pain and diagnostic nasal endoscopic findings. During surgery, area around the lacrimal sac was found to be inflamed and a tissue biopsy was taken. It revealed multiple sporangia and sporocysts of R. seeberi with chronic inflammation.\nIn view of the diagnosis, it was decided to excise the lacrimal sac after counseling the patient about postoperative epiphora. Right dacryocystectomy was performed under local anesthesia. There was brisk intraoperative bleeding. The sac was removed completely along with nasolacrimal duct with wide excision and generous electrocauterization of the surrounding margins. The wall of nasolacrimal duct was also cauterized. The lacrimal sac fossa was copiously irrigated with 5% povidone-iodine solution.\nOn histopathological examination, the lacrimal sac showed fibrocollagenous tissue with dense lymphocytic infiltration. Multiple vascular channels were seen with areas of hemorrhage. Numerous sporocysts in various stages of maturation were seen just underneath the stratified squamous epithelium of the lacrimal sac [].\nThe patient has been counseled about the chances of recurrence of infection and advised periodic checkup.