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| CASE REPORT |
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| Year : 2020 | Volume
: 9
| Issue : 2 | Page : 192-194 |
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Otomycosis due to Aspergillus versicolor
Santosh Kumar Swain1, Priyanka Debta2, Mahesh Chandra Sahu3, Jatindra Nath Mohanty4
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
2 Department of Oral Pathology and Microbiology, IDS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
3 Division of Microbiology, ICMR-National Institute of Occupational Health, Ahmedabad, Gujarat, India
4 Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University (Deemed to be), Bhubaneswar, Odisha, India
| Date of Submission | 06-Jan-2020 |
| Date of Decision | 03-Jan-2020 |
| Date of Acceptance | 18-Jan-2020 |
| Date of Web Publication | 9-Apr-2020 |
Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Bhubaneswar, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijhas.IJHAS_89_19
Otomycosis is a common clinical entity seen in both immunocompetent and immunocompromised patients. Aspergillus and Candida are the most common causative fungi in otomycosis. Aspergillus versicolor is an extremely rare causative agent for otomycosis. The clinical symptoms presented by patients are usually itching of the ear canal, otalgia, and discharge from the ear. The diagnosis of otomycosis is done on the basis of clinical presentations, microscopy and culture. The correct identification of A. versicolor is often challenging in routine clinical practice. Successful treatment of otomycosis due to A. versicolor requires prompt diagnosis and immediate treatment as delay or nontreatment may lead into rapid spread of this infection with lethal outcome. Here, we are presenting a case of an immunocompetent male presented with itching, ear discharge, pain, and ear block due to otomycosis caused by A. versicolor.
Keywords: Aspergillus versicolor, immunocompetent patient, otomycosis
How to cite this article:
Swain SK, Debta P, Sahu MC, Mohanty JN. Otomycosis due to Aspergillus versicolor. Int J Health Allied Sci 2020;9:192-4 |
| Introduction | |  |
Otomycosis is a fungal infection of the pinna, external auditory canal, and tympanic membrane.[1] It often presents with itching in the ear canal, pain, otorrhea, and decreased hearing. Otoscopic examination shows grayish-white and black or cheesy appearance and inflammation of the outer ear canal.[2] The predisposing factors for otomycosis are hot weather, head clothes, self-cleaning of the ear canal, dusty environment, swimmers, and presence of dermatomycoses.[3] The prevalence of otomycosis is more in young adults with predominance among females.[3] Fungal infections in the external auditory canal are often seen among immunocompetent patients. It is commonly encountered in tropical countries. The pathogens detected from otomycosis are fungi such as Aspergillus niger, Aspergillus flavus, Aspergillus fumigatus, and Candida albicans. The most common fungus isolated from otomycosis is A. niger.[4] Here, we are presenting a case of otomycosis with causative agent of Aspergillus versicolor which is rarely reported in medical literature.
| Case Report | | |
A 32-year-old male attended the outpatient department of otolaryngology with complaints of itching of the right external auditory canal, pain, ear block sensation, and scanty watery discharge for 1 month. Onset was insidious and gradually progressive in nature. He had no history of diabetes mellitus, antihypertensive, not taking prolonged immunosuppressive agents or corticosteroids or antibiotics, and no prolonged history of ear discharge. He had a regular habit of self-cleaning of the ear canal by earbuds. The otoscopic examination showed the presence of white-grayish mass plugging the right external auditory canal. The whitish, grayish mass from the ear canal was removed with the help of suction cleaning. The material from the ear canal was also sent for fungal culture. Potassium hydroxide (KOH) (10%) mount revealed hyaline septate hyphae with acute-angled branching [Figure 1]. The specimen inoculated in the Sabouraud dextrose agar (SDA) and incubated at 37°C [Figure 2]. It showed small pink to flesh-colored velvety colonies on the 8th day of culture. In successive days of incubation, the color of the colony changed from orange yellow to green. In lactophenol cotton blue (LPCB) tease mount of colonies showed septate and hyaline hyphae with acute-angled branching [Figure 3]. There were small conidial heads, consisting of ovoid vesicle bearing metulae beneath the layer of phialides and reduced conidial structures mimicking to the Penicillium species were present. These features suggest of A. versicolor. The patient was treated with tablet terbinafine 250 mg/day for 3 weeks and topical terbinafine applied topically twice daily. The patient's symptoms were improved after 3 weeks. The patient was reviewed after 3 months and showed normal external auditory canal and eardrum without evidence of any fungal debris. | Figure 1: Fungal hyphae of Aspergillus versicolor in potassium hydroxide staining (×10)
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 | Figure 3: Lactophenol cotton blue mount of colony (Aspergillus versicolor) in Sabouraud dextrose agar
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| Discussion | | |
Otomycosis is a superficial fungal infection in the external ear which often requires long-term treatment and tends to recur. Prolonged use of topical antibiotic ear drops and use of Q tips aggravate the fungal infections in the external auditory canal. Immunocompromised patients such as diabetes mellitus or HIV infections often lead to refractory fungal infections of the external ear. Habit of self-cleaning of the ear canal is a common triggering factor for causing otomycosis as in our case. Self-cleaning with the help of unsterile sticks/feathers/hair pins/rolled papers are often practiced by many patients before developing otomycosis. Habit of cleaning with such contaminated objects makes inoculation of fungus in the external auditory canal, and further it damages the normal lining epithelium which is a natural defense barrier and protects from infections. Other predisposing factors are lack of cerumen, chronic otitis media, application of oil into the ear canal, swimming in the infected water, and prior prolonged antibiotic or steroid therapy. Chronic otitis media with perforated tympanic membrane often have associated otomycosis due to the presence of constant moisture in the external auditory canal.[5] Andrall and Gaverret were first documented the otomycosis as a superficial fungal infection of the external auditory canal.[6] This infection may be either acute or subacute and characterized by itching, otalgia, mild hearing loss, superficial epithelial exfoliation and debris containing fungal hyphae, and spores in the ear canal. A. fumigatus is the most common etiological agent in otomycosis, followed by A. niger, A. Flavus, and C. albicans.[7] In one study, A. niger is the most commonly identified fungus, followed by A. flavus and Aspergillus fumigates.[8] However, other causative agents include Scopulariopsis, Allescheria boydii, Rhizopus, and Absidia.[9] In this case, A. versicolor identified as etiological agent. A. versicolor is rarely reported as a causative agent for otomycosis. A. versicolor is an opportunistic slow-growing mold, rarely reported as an etiological agent for otomycosis. It is usually found in damp indoor environment. It is commonly reported as a causative agent for onychomycosis, cutaneous disease, ocular disease, and osteomyelitis.[10] It has been reported often as a colonizer at the respiratory tract. However, it is rarely reported as a causative agent for otomycosis. Apart from the release of hepatotoxic and carcinogenic mycotoxin sterigmatocystin, it also possesses more than twenty allergens which irritate the nose, eyes, and throat.[11]A. versicolor is a common causative agent for onychomycosis. The diagnosis is done by both culture and microscopy.[12] In this case, findings of KOH mount variable color changes of colony on SDA, and characteristic structure on LPCB is suggestive of A. versicolor. Although A. versicolor is rarely reported as etiology for otomycosis and fungal sinusitis, it is reported as causal agent in cerebral abscess and endogenous endophthalmitis in immunocompetent host.[13] The exact identification of A. versicolor is often challenging as usually the presence of reduced penicillium-like structures on LPCB examination, leading into misidentification of this fungus as penicillium spp.[14] However, the simultaneous presence of the typical vesicles of Aspergillus spp and penicillium-like hyphae may be mistaken as mixed growth of contaminated fungi. This varied morphological appearance may lead to underreporting of this fungus. Hence, A. versicolor is suspected when the characteristic biseriate vesicles and reduced penicillium-like structures are seen in a fungus. The identification of globose Hulle cells can be an additional clue for the confirmation of this fungus.[14] Before treating otomycosis, the aggravating factors such as use of prolonged corticosteroids/antibiotics or self-cleaning should be taken into consideration. Self-cleaning of the ear canal should be stopped. This fungus is usually resistant to griseofulvin, fluconazole, and amphotericin B (drug of choice for Aspergillus spp.) and sensitive to ketoconazole and itraconazole, but their inhibiting concentrations range from 0.50 to 4.0 Ìg/ml. Terbinafine is an effective agent for this fungal infection as it has very low minimum inhibitory concentration (0.125 Ìg/ml).[15] Treatment in this case was done with terbinafine 250 mg/day for 1 month and topical terbinafine was applied locally. The clinical presentations were improved with the help of this treatment. On otoscopical examination, no fungal elements were seen after treatment.
| Conclusion | | |
A. versicolor is an uncommon human pathogen for causing otomycosis. It is an opportunistic mold and extremely rare for causing otomycosis. It is a ubiquitous fungus isolated from buildings contaminated with molds in tropics and moist environment. It releases metabolites which are involved in tumor genesis. The demonstration of A. versicolor is confirmed by microscopy and culture. Early identification is required to avoid destructive disease and to initiate early treatment before irreversible situation. As it is extremely rare etiology for otomycosis, further identification by molecular level is required.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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