Conjunctival Rhinosporidiosis

Conjunctival Rhinosporidiosis-various aspects-

Conjunctival Rhinosporidiosis: A Comprehensive Overview

Introduction

Conjunctival rhinosporidiosis is a rare, chronic granulomatous infection of the conjunctiva caused by Rhinosporidium seeberi. It is part of a larger clinical spectrum called rhinosporidiosis, which can involve the nasal mucosa, nasopharynx, skin, genitals, and, less commonly, the eye and its surrounding structures.

The ocular form typically presents as a mass on the bulbar or palpebral conjunctiva. Although it’s relatively uncommon, its distinct appearance and potential complications make awareness and prompt management crucial, particularly in endemic areas.

Etiology and Causative Agent

Rhinosporidium seeberi is the causative agent of rhinosporidiosis. It was initially thought to be a fungus due to its sporangial structure, but modern molecular studies have classified it under the class Mesomycetozoea — a group of aquatic protists that are phylogenetically placed between fungi and animals.

This pathogen primarily enters the body through traumatized epithelium when individuals come into contact with contaminated water sources such as ponds or stagnant lakes. The conjunctiva can become infected through direct exposure to water or via contaminated fingers or cloths.

If Any Patient of ENT Requires Any Surgery, Opd Consultation Or Online Consultation In Clinic of  ENT Specialist Doctor Dr. Sagar Rajkuwar ,He May Contact Him At The Following Address-
Prabha ENT Clinic, Plot no 345,Saigram Colony, Opposite Indoline Furniture Ambad Link Road ,Ambad ,1 km From Pathardi Phata Nashik ,422010 ,Maharashtra, India-Dr. Sagar Rajkuwar (MS-ENT), Cell No- 7387590194, 9892596635

Epidemiology

Rhinosporidiosis is endemic in South Asia, particularly in:

• India (notably in the states of Tamil Nadu, Kerala, Odisha)
• Sri Lanka
• Parts of Bangladesh, Nepal, and Pakistan

However, sporadic cases have also been reported in Africa, South America, and rarely in Europe and North America, usually due to immigration or travel to endemic regions.

• Age group: It can affect all ages but is most commonly seen in young males between 15 to 40 years.
• Risk factors:
  ◦ Bathing in stagnant or contaminated water
  ◦ Agricultural work
  ◦ Rural residency
  ◦ Poor ocular hygiene

Pathophysiology

Once the sporangia of Rhinosporidium seeberi enter the conjunctival tissue, they mature and cause chronic granulomatous inflammation. The infection leads to the development of polypoidal, highly vascular masses that may bleed easily upon manipulation.

Histologically, the lesion is characterized by:

• Large, thick-walled sporangia containing numerous endospores
• Surrounding granulomatous inflammation
• Mixed inflammatory cell infiltrate, including lymphocytes, plasma cells, and macrophages

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Clinical Features

The most common clinical presentation of conjunctival rhinosporidiosis includes:

• Red, fleshy, polypoidal mass on the conjunctiva
• Often appears pedunculated or sessile
• May be bleeding or covered with white dots (representing sporangia)
• Unilateral involvement is more common
• No pain, but patients may report:
  ◦ Foreign body sensation
  ◦ Mild irritation
  ◦ Epiphora (watering of eyes)
  ◦ Visual obstruction (if lesion is large)

Sites of involvement:

• Palpebral conjunctiva (especially tarsal)
• Bulbar conjunctiva
• Fornices
• Caruncle
• Lacrimal sac (less commonly)

Diagnosis

1. Clinical Examination

An ophthalmologist can suspect the diagnosis based on the appearance of a red, vascular, pedunculated mass with white dots.

2. Histopathology (Gold standard)

• Hematoxylin and eosin (H&E) staining reveals:

◦ Mature and immature sporangia
◦ Endospores within the sporangia
◦ Chronic inflammatory infiltrate

3. Special Stains

• Periodic acid-Schiff (PAS) and Gomori methenamine silver (GMS) stains highlight the wall of the sporangia.

4. Molecular Techniques

Rarely used in routine practice but helpful in research settings — PCR and rDNA sequencing have confirmed classification under Mesomycetozoea.

Differential Diagnosis

• Pyogenic granuloma
• Conjunctival papilloma
• Hemangioma
• Squamous cell carcinoma (especially in older patients)
• Kaposi sarcoma (in HIV patients)
• Ocular cysticercosis

Histopathology helps to distinguish rhinosporidiosis from these entities.

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Management

1. Surgical Excision

• Complete excision of the lesion is the treatment of choice.
• Base of the lesion should be cauterized or treated with electrocoagulation to reduce recurrence.
• Great care must be taken to avoid rupture of sporangia during surgery to prevent autoinoculation or recurrence.

2. Medical Therapy

• Rhinosporidium seeberi is resistant to most antifungal and antibacterial drugs.
• Dapsone (100 mg/day for several months) has been used as an adjunct to:

◦ Arrest maturation of sporangia
◦ Promote fibrosis
◦ Reduce recurrence

However, its efficacy remains controversial and not universally accepted.

Complications

• Recurrence of the lesion (due to incomplete excision or autoinoculation)
• Scarring or fibrosis of conjunctiva
• Cosmetic disfigurement
• Rarely, spread to:
  ◦ Lacrimal sac (causing dacryocystitis)
  ◦ Orbit (causing proptosis)
  ◦ Nasal cavity (if conjunctival lesion extends)

Prevention

• Avoid bathing in contaminated or stagnant water, especially in endemic regions
• Maintain good ocular hygiene
• Do not rub eyes with unclean hands or cloths
• Community education in endemic regions about safe water practices

Prognosis

• With complete surgical excision, prognosis is generally good.
• Recurrence rate can vary between 10-25%, depending on surgical technique.
• Ocular rhinosporidiosis is non-fatal and does not usually impair vision unless complications arise.

Conclusion

Conjunctival rhinosporidiosis, though rare, should be considered in the differential diagnosis of conjunctival masses in patients from endemic areas or with a history of bathing in stagnant water. Accurate clinical recognition and complete surgical excision are the keys to effective treatment. Continued public health awareness and research are necessary to better understand and manage this unusual but significant ocular infection.

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Clinic address of ENT SPECIALIST doctor Dr Sagar Rajkuwar-

Prabha ENT clinic, plot no 345,Saigram colony, opposite Indoline furniture Ambad link road ,Ambad ,1 km from Pathardi phata Nashik ,422010 ,Maharashtra, India-Dr Sagar Rajkuwar (MS-ENT), Cel no- 7387590194 , 9892596635