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The Official Scientific Journal of Delhi Ophthalmological Society
Ocular Rhinosporidiosis Presenting As A Rapidly Growing Conjunctival Papilloma
Kanika Jain, Taru Dewan, Purnima Paliwal, Manav Deep Singh, Sonali Gupta 
Department of Ophthalmology, Dr RML Hospital, PGIMER, New Delhi, India
Corresponding Author:
Kanika Jain MS 
Post Graduate
PGIMER, Dr. R M L Hospital, New Delhi
Email id: kanikajain024@gmail.com 
Received: 8-SEP-2017 Accepted: 27-SEP-2017 Published Online: 03-MAR-2018
DOI: http://dx.doi.org/10.7869/djo.331
Abstract
A 24 year old male, resident of Delhi, presented with complaints of a painless progressive reddish lump on the lower surface in the left eye since the past two months. On examination, a sessile 10 X 6 mm wide fleshy pink, highly vasular mass was present in the middle 2/3rd of the lower palpebral conjunctiva of the left eye. The patient was clinically diagnosed as a case of conjunctival papilloma and underwent wide surgical excision. Histopathological evaluation revealed this to be ocular rhinosporidiosis. No history suggestive of as to how the infection was acquired was obtained and other mucous memberanes were unaffected which were evaluated postoperatively to rule out other sites of inoculation. The largest reported case series of rhinosporidiosis of 462 cases in South Western India found that the disease mainly occurs in the nose and nasopharynx (81.1%), while eyes were affected in 14.2%. Many case series of ocular rhinosporidiosis from South and Southwestern India have been reported but no case reports could be found from Northern India. This case highlights the importance of histopathological evaluation of all conjunctival lesions which helps in the proper diagnosis of the case and its appropriate management. 
Keywords : ocular rhinosporidiois, rhinosporidium seeberi, conjunctival papilloma

Introduction
Rhinosporidiosis is a chronic granulomatous infection of mucous memberanes (nasal, oral, ocular, genital and rectal) caused by Rhinosporidium seeberi.1 This is an unusual pathogen which is difficult to culture and was previously considered to be a fungus and classified as fungal disease under ICD 10. It is now considered as a protist2 classified under Mesomycetozoa “meso-in the middle of, “-myceto-fungi and “-zoea” -animals. This is a heterogenous group of microorganisms at the animal fungal boundary. These are a small group of protists, which are mostly parasites of fish and other animals. The disease is endemic in South India, Sri Lanka, South America and Africa. It is presumed to be transmitted by exposure to the pathogen when taking a bath in stagnant water pools where animals also bathe. Traumatic auto-inoculation from one site to another is common. It affects both adults and children. Floor and inferior turbinate are the most common sites of inoculation presenting as unilateral nasal obstruction, epistaxis or rhinorrhea. Ocular rhinosporidiosis most often presents as a polypoid mass of the palpebral conjunctiva.3 It may also present as a lacrimal sac diverticulum,4 recurrent chalazion,5 conjunctival cyst,6 chronic follicular conjunctivitis in contact lens wearers,7 peripheral keratitis,8 scleral melting,9 ciliary staphyloma10 or simulate a tumour of eyelid11 or periorbital skin.12 The diagnosis is confirmed by histopathology of the biopsied specimen. Definitive management is wide surgical excision with wide area electrocoagulation of the lesion base. Recurrences are rare.13 

Case Presentation
A 24 year old male, resident of Delhi since the past five years, presented to our hospital in November, 2016 with complaints of a appearance of a painless progressive reddish lump on the lower surface in the left eye since the past two months. The patient belonged to a lower socio-economic strata and there was no history of recent travel, ocular trauma, swimming in stagnant water or water where animals bathe. On examination, a sessile 10 x 6 mm wide fleshy pink mass was present in the middle 2/3rd of the lower palpebral conjunctiva of the left eye (Figure 1a and 1b). It had a papilliform, friable surface and was a highly vascular lesion with scarring at the end of the stalk of the growth. There was no associated petechiae, bleeding points, pigmentation, ulceration, discharge, conjunctival injection and the rest of the ocular examination was normal. A clinical diagnosis of conjunctival papilloma was made and the patient underwent wide surgical excision with cauterization of the base under local anaesthesia. Histopathological examination showed tissue lined by hyperplastic stratified squamous epithelium with neutrophilic micro-abscesses. The subepithelium showed edema, mixed inflammatory infiltrate and many intact/ ruptured sporangia of rhinosporidiosis. Abundant fibrino-suppurative exudate was also noted (Figure 2 & 3). A diagnosis of ocular rhinosporidiosis was made. With this diagnosis in mind, the patient underwent detailed nasopharyngeal and genital evaluation to rule out any other site of rhinosporidial inoculation. Three month follow up following excision showed no recurrences (Figure 4).





Discussion
The case presented with a highly vascular rapidly growing lesion in the left lower palpebral conjunctiva. The patient was clinically diagnosed as a case of conjunctival papilloma and underwent wide surgical excision with electrocautery of the base. The specimen on histopathological evaluation revealed this to be ocular rhinosporidiosis. No history suggestive of as to how the infection was acquired was obtained and other mucous memberanes were unaffected which were evaluated postoperatively to rule out other sites of inoculation. The largest reported case series of rhinosporidiosis of 462 cases in Southwestern India found that the disease mainly occurs in the nose and nasopharynx (81.1%), while eyes were affected in 14.2%.14 Another case series of 34 patients from South India found nasal and nasopharyngeal involvement in 85% while eyes were affected in 9% of cases.15 A case involving multiple mucous memberanes has also been reported in India.16 Many case series of ocular rhinosporidiosis from South and Southwestern India have been reported but no case reports could be found from Northern India.14-16 This case highlights the importance of histopathological evaluation of all conjunctival lesions which helps in the proper diagnosis of the case and its appropriate management.

Conclusion
Ocular rhinosporidiosis mimicking a conjunctival papilloma with a short history of growth can occur in the affluent areas of Delhi.

References
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  2. Morelli L, Polce M, Piscioli F, Del Nonno F, Covello R, Brenna A, et al. Human nasal rhinosporidiosis: an Italian case report. Diagn Pathol 2006; 1:25.
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  5. Mukhopadhyay S, Shome S, Bar PK, Chakrabarti A, Mazumdar S, De A, et al. Ocular rhinosporidiosis presenting as recurrent chalazion. Int Ophthalmol 2015; 35:705-7. 
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  8. Bhomaj S, Das JC, Chaudhuri Z, Bansal RL, Sharma P: Rhinosporidiosis and peripheral keratitis. Ophthalmic Surg Lasers 2001; 32:338-40.
  9. De Doncker RM, de Keizer RJ, Oosterhuis JA, Maes A. Scleral melting in a patient with conjunctival rhinosporidiosis. Br J Ophthalmol 1990; 74:635-7. 
  10. Talukder AK, Rahman MA, Islam MN, Chowdhury MH. Ciliary staphyloma: very rare sequelae of conjunctival rhinosporiodosis. Mymensingh Med J 2004; 13:86-7.
  11. Sharma KD, Shrivastav JB, Agarwal S. Ocular rhinosporidiosis simulating a tumour. Br J Ophthalmol 1958; 42:572-4. 
  12. Vallarelli AF, Rosa SP, Souza EM. Rhinosporidiosis: cutaneous manifestation. An Bras Dermatol 2011; 86:795-6. 
  13. Mithal C, Agarwal P, Mithal N. Ocular and adnexal rhinosporidiosis : the clinical profile and treatment outcomes in a tertiary eye care centre. Nepal J Ophthalmol 2012; 4:45-8.
  14. Sudarshan V, Goel NK, Gahine R, Krishnani C. Rhinosporidiosis in Raipur, Chhattisgarh: a report of 462 cases. Indian J Pathol Microbiol 2007; 50:718-21.
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Kanika Jain, Taru Dewan, Purnima Paliwal, Manav Deep Singh, Sonali GuptaOcular Rhinosporidiosis Presenting As A Rapidly Growing Conjunctival Papilloma.DJO 2018;28:32-34
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Kanika Jain, Taru Dewan, Purnima Paliwal, Manav Deep Singh, Sonali GuptaOcular Rhinosporidiosis Presenting As A Rapidly Growing Conjunctival Papilloma.DJO [serial online] 2018[cited 2018 Jul 19];28:32-34. Available from: http://www.djo.org.in/articles/28/3/OcularRhinosporidiosisPresentingAsARapidlyGrowingConjunctivalPapilloma.html
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