Photo Quiz: Not-So-Humongous Fungus or an Imposter?

A 61-year-old female with a 5-year history of chronic sinusitis and intermittent ear pain had incomplete responses to numerous courses of antibiotics. Seasonal allergies often heralded sinusitis episodes. She did not smoke and used alcohol rarely. Her history was notable for a maxillofacial procedure in 1984, for which no further details are available. On physical examination, the tympanic membranes were normal bilaterally. Anterior nasal examination and nasal endoscopy revealed a deviated septum, with purulence emanating from the left inferior meatus. A computed tomography (CT) scan revealed a completely obstructed right maxillary sinus, evidence of prior maxillomandibular advancement with wires, and a deviated nasal septum. Bilateral maxillary antrostomy and septoplasty were performed with resection of the left concha bullosa. At surgery, the clinical impression of a large fungus ball was noted; the commingled sinus contents were sent for bacterial culture, fungal culture, and histological analysis. Routine hematoxylin and eosin stain of the tissue section demonstrated chronically inflamed sinus mucosa and fragments of eosinophilic, amorphous debris. The microbiology laboratory was consulted to review periodic acid-Schiff (PAS) and Grocott methenamine silver (GMS) stains on paraffin-embedded tissue (Fig. 1); each stain demonstrated numerous slender filamentous organisms with slight terminal nodularity in the eosinophilic debris. Direct Gram stain of the specimen received in the microbiology laboratory showed a moderate number of white blood cells, many red blood cells, few Gram-negative bacilli, and many filamentous Gram-positive bacilli. FIG 1 GMS stain from paraffin-embedded sinus contents (magnification, ×1,000). (For answer and discussion, see page 2004 in this issue [doi:10.1128/JCM.01589-13].)