Hindawi Publishing Corporation Case Reports in Infectious Diseases Volume 2016, Article ID 6536275, 5 pages http://dx.doi.org/10.1155/2016/6536275 Case Report Rhinoscleroma with Pharyngolaryngeal Involvement Caused by Klebsiella ozaenae J. Gonzales Zamora1 and A. R. Murali2 1 Division of Infectious Diseases, Augusta University, Augusta, GA 30912, USA 2Department of Gastroenterology, University of Iowa Hospital and Clinics, Iowa City, IA 52242, USA Correspondence should be addressed to J. Gonzales Zamora; [email protected] Received 16 January 2016; Accepted 28 April 2016 Academic Editor: Sinesio´ Talhari Copyright © 2016 J. Gonzales Zamora and A. R. Murali. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rhinoscleroma is a chronic, slowly progressive granulomatous bacterial infection that is endemic to the tropical world, namely, Central America and Africa. It is occasionally seen in the United States of America (USA). It predominately affects the nasal mucosa but can also involve the rest of the upper respiratory tract. The well-known causative agent for rhinoscleroma is the bacterium Klebsiella rhinoscleromatis, a subspecies of Klebsiella pneumoniae.However,Klebsiella ozaenae can also, albeit very rarely, cause rhinoscleroma. The diagnosis is confirmed by histopathology examination that shows the characteristic Mikulicz cells, considered pathognomonic for this infection. We report a patient with histologically proven rhinoscleroma with pharyngolaryngeal involvement in whom cultures yielded Klebsiella ozaenae. To the best of our knowledge, only two cases of rhinoscleroma due to Klebsiella ozaenae have been reported in the literature to date. Our case illustrates the importance of recognizing this infection in a nonendemic setting such as the USA. A lack of awareness and a delay in the diagnosis of this disease can lead to complications including upper airway obstruction, physical deformity, and, rarely, sepsis. In addition, it must be remembered that the treatment of rhinoscleroma is challenging and requires a prolonged course of antibiotics to achieve a definite cure and avoid relapses. 1. Introduction 2. Case Report Rhinoscleroma is a chronic granulomatous infection that A 47-year-old male originally from Mexico presented to our affects the upper respiratory tract from the nose down to the hospital with persistent nasal congestion, sore throat, hoarse- trachea. This disease is found primarily in impoverished areas ness of voice, and dysphagia. His symptoms first started of the Middle East, Eastern Europe, Africa, and Central and 23 years before while in Mexico. At that time, he reported South America. It is reported uncommonly in the USA, where having had multiple episodes of epistaxis and the presence cases are seen in immigrants from endemic countries. The of an “extra skin” in his nose. He also reported that he bacterium implicated as the causative agent of this infection had a surgical procedure at initial presentation in which is Klebsiella rhinoscleromatis.However,Klebsiella ozaenae, his “nostrils were scraped” and subsequently was put on which is typically associated with primary atrophic rhinitis, antibiotics for 6 months (patient unaware of the name of has also been reported as a cause of rhinoscleroma in only 2 the antibiotics he received). His symptoms improved, only previous case reports. Rhinoscleroma predominantly affects to resurface ten years later. Shortly thereafter, he moved to the nose; other areas of the respiratory tract such as the larynx the USA. He experienced progressive worsening of nasal or oropharynx are affected in a minority of patients. We congestion, difficulty swallowing, and hoarseness of voice describe a rare case of rhinoscleroma with pharyngolaryngeal and went to a primary care physician for evaluation. He involvement due to Klebsiella ozaenae in a patient hailing received 3 doses of intramuscular ceftriaxone followed by oral from Mexico. antibiotics. He reported a mild clinical improvement followed 2 Case Reports in Infectious Diseases This infection was first described in 1870 by Von Hebra [1]; seven years later, Mikulicz described the histology and the characteristic foam cells that bear his name [2]. In 1882, Von Frisch [3] identified the causal agent now known as Klebsiella rhinoscleromatis. This infection is prevalent in rural areas with poor sanitation and is considered endemic in Africa, Southeast Asia, and Central and South America. Although most cases occur in developing countries, recent immigration patterns have led to an increasing number of patients with Figure 1: Erythematous tissue with white exudates covering the rhinoscleroma in the USA [4]. oropharynx. The mode of transmission is not well understood, but itis probably through contaminated airborne particles, which are expelledbycoughingandsneezingorbycontactwithfomites. An epidemiologic study that included 11 cases published by rapid relapse with continued symptoms progression. He byDePontualetal.foundthat3outof11patientshada presented to our hospital for further evaluation. By the time significant family history of rhinoscleroma [5]. These findings of hospital presentation, in addition to the above symptoms suggest that transmission could be secondary to prolonged the patient also noted a mass protruding into the back of his household contact with infected family members. A genetic throat. He denied weight loss, fever, or chills. His past medical predisposition is also possible since mutations affecting genes history was significant for treated pulmonary tuberculosis that encode components of S-nitrosoglutathione reductase attheageof16.Hedeniedanycigarettesmoking,drug (GSNOR) have been found to increase the susceptibility to use, or alcohol intake. His family history revealed that his Klebsiella pneumonia infection in mice [6]. The haplotype ∗ ∗ maternal uncle and his oldest son had constant rhinorrhea HLA-DQA1 03011-DQB 0301 has been another important and his mother had a mass in her nose, but all affected family factor associated with the development of this disease [7]. Of members remained in Mexico with limited access to medical note,ourpatienthad3relativeswithapresumptivehistoryof care. Physical exam showed an erythematous, irregular soft rhinoscleroma. tissue lesion covering the entire posterior oropharynx with This infection is typically divided into three stages: some white exudate (Figure 1). The mucosa of the nares had catarrhal, granulomatous, and fibrotic. The catarrhal stage a similar appearance, but no discreet mass was appreciated. causes symptoms of nonspecific rhinitis that can last for The remainder of the exam was unremarkable. × × weeks to months and often evolves into purulent and fetid Computed tomography of the neck showed a 21 24 rhinorrhea with crusting. The granulomatous stage results in 25 mm mass in the soft palate narrowing the nasopharynx × the development of a bluish red nasal mucosa and intranasal (Figure 2(a)) and a lesion of 15 9mm in the anterior rubbery nodules or polyps. Epistaxis, nasal deformity, and aspect of the left false vocal cord (Figure 2(b)). There was destruction of the nasal cartilage may also be noted (Hebra also an asymmetric thickening of the left tonsil. No cervical nose). The third stage is characterized by extensive fibrosis adenopathy was detected. An esophagogram did not reveal leading to extensive scarring and possible nasal/laryngeal any evidence of obstruction. stenosis. Otolaryngology was consulted and performed biopsies of Theareasoftherespiratorytractthataretypically the oropharyngeal mass and the left tonsil. Tissue was submit- involved are the nasal cavity and nasopharynx. This infection ted for pathology and microbiology studies. Histopathology may also affect the larynx, trachea, bronchi, the middle ear, withhematoxylinandeosin(H&E)stainrevealedplasma oral cavity, paranasal sinuses, orbit, and soft tissues of the lips. cell infiltrates mixed with foamy macrophages, known as Fawaz and colleagues published one of the largest cases series Mikulicz cells (Figure 3(a)). These findings were consistent of rhinoscleroma in Egypt, which included 88 patients. In this with rhinoscleroma. Gomori methenamine silver (GMS) review, the nose was compromised in 100% of the cases. Pha- stain was also performed and showed intracellular coc- ryngeal rhinoscleroma was found in only 9 (10%) patients, cobacilli (Figure 3(b)). Tissue cultures yielded Klebsiella whereas pharyngolaryngeal involvement occurred in 19 ozaenae, resistant only to ampicillin. The automated system (21.5%) cases. Involvement of the trachea was only reported used to identify this isolate was the MicroScan Walkaway 96 in 1 (1%) case [8]. Our patient had involvement of multiple (Siemens, Sacramento, California). sites that included the nose, soft palate, and false vocal cords, The patient was started on trimethoprim-sulfamethoxa- which is a relatively uncommon manifestation of this disease. zole but developed body aches and cramps as side effects. The diagnosis is usually confirmed with histopathology Therapy was subsequently changed to ciprofloxacin and revealing the characteristic Mikulicz cells, Russel bodies, and doxycycline, planning to complete a six-to-twelve-month positive Warthin-Starry stains. It is typically described that course. Unfortunately, he was subsequently lost to follow-up. routine cultures are positive for