Klebsiella rhinoscleromatosis:Short, encapsulated, and immotile Gram-negative bacillus with an affinity for nasal mucosa.
- Transmission: Direct/indirect contact with nasal exudate of infected person
- Disease predominantly occurs in middle-aged woman, living in poor hygienic and nutritional condition.
- Involved sites:
- Nasal cavity (M/C involved, 95–100%)
- Nasopharynx (18–43%)
- Larynx (15–40%)
- Trachea (12%)
- Bronchi (2–7%)
Catarrhal (rhinitic) stage:Nonspecific rhinitis that evolves into chronic foul smelling purulent discharge, epistaxis, crusting, and nasal obstruction.
Granulomatous (proliferative/nodular) stage:Clinical features are more prominent in granulomatous phase. In this phase, patient develops granulomatous nodular mass which leads to nasal obstruction. If left untreated patient goes into sclerotic phase.
- Woody/Hebra nose
Sclerotic (cicatricial/fibrotic) stage:Permanent complications are characteristic at this stage.
- Nasal deformities
- Oral anesthesia
- Dysphonia, dysphasia, and stridor
Tissue biopsy:Histopathology is the mainstay in the diagnosis of rhinoscleroma. Intracytoplasmic bacilli can be demonstrated by special stains using Gram, PAS, Geimsa, Warthin-Starry, and Grocott’s silver methenamine stains. The detection of Type III Klebsiella antigen, CD 68 and altered CD4:CD8 ratio are helpful in the diagnosis.
- Catarrhal stage: Nonspecific subepithelial infiltrate of polymorphonuclear leukocytes with granulation tissue
- Granulomatous stage: Dense infiltration of lymphocytes, plasma cells, russell bodies, and pathognomonic large Mikulicz cells
- Russell bodies: Homogenous eosinophilic inclusion bodies
- Mikulicz cells: Atypical foamy monocytes containing causative bacilli
- Sclerotic stage: Extensive fibrosis and less inflammatory cell infiltration
Rhinoscleroma is a diagnostic and therapeutic challenge due to its chronic course, need for prolonged treatment and repeated relapses.
Antibiotic therapy:Mainstay of treatment. Patient is kept under regular observation to monitor any incidence of recurrence.
- Tetracycline (2g/day) + streptomycin (1g/day) for 1 month and continued till 2 consecutive negative biopsies
Surgical management:Indicated in permanent deformities