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Lacrimal sac rhinosporidiosis is an uncommon infection and to our knowledge has not been reported in Canada. Rhinosporidium seeberi is a fungus-like parasite with an evolutionary origin near the animal-fungal divergence that causes chronic infection of the mucous membranes of the upper respiratory tract.
A healthy 35-year-old female presented with acute onset unilateral bloody tears. There was no history of trauma, recent travel, or other constitutional symptoms. She resided in Bangladesh before immigration to Canada 14 years earlier. Examination revealed copious bloody, mucopurulent discharge from the left upper and lower puncta, with spurting during manual lacrimal sac compression. There was tenderness in the medial canthal region and mild swelling, but no erythema or warmth. Ocular, orbital, and nasal speculum examinations were otherwise normal. The patient began a course of oral cephalexin and the bloody tears resolved at 1 week, but the discomfort persisted. The improvement could have been related to clearance of bacterial superinfection. The lacrimal system was patent to irrigation. A computed tomography scan (Fig. 1) showed a left lacrimal sac mass, without bone destruction. The mass showed central gadolinium enhancement with magnetic resonance imaging, with loculated fluid peripheral to the mass, and dilatation of the upper part of the left nasolacrimal duct. An open excisional biopsy was performed. Frozen sections showed fungal elements and no evidence of neoplasm; therefore a left external dacryocystorhinostomy was performed. Permanent sections revealed features pathognomonic for R. seeberi infection (Fig. 2). Innumerable cystic structures, many filled with amorphous material surrounded by a thick, sometimes birefringent, capsule were seen. Occasional cysts contained spores, with the majority of cysts either impinging on the overlying mucosa or present in the immediate submucosa. The postoperative course was unremarkable. Infectious disease consultation deemed systemic dapsone treatment unnecessary. The patient has been followed for more than 5 years without recurrence.
Ocular rhinosporidiosis accounts for 15% of R. seeberi infections, with conjunctival involvement in the majority of cases.
support the possibility of the organism existing locally in our temperate climate.
Reported features of lacrimal sac rhinosporidiosis include painless, soft, fluctuant swelling of the lacrimal sac with partial nasolacrimal duct obstruction, and epistaxis, although our patient did have tenderness that is atypical. The dilated lacrimal sac often contains polypoidal growths or diverticula.