A previously well 9-year-old girl presented with excess tearing and mild discomfort to the left side of her nose. She was not otherwise ill, and there was no history of trauma, sinusitis, or eye disease. There was no involvement of the contralateral eye. She was a dancer who frequently used eye makeup. She had no response to a variety of oral and topical antibiotics. She was diagnosed with chronic dacryocystitis and nasal lacrimal duct obstruction. She underwent surgical exploration and biopsy, which showed granulomatous inflammation and hyphal elements. No cultures were obtained. Postoperatively, a pustule developed at the incision site, and her eye continued to water. She had no fever and otherwise felt well. She was again treated with oral and topical antibacterial agents as well as oral fluconazole, without response. A computed tomography scan demonstrated orbital abscess. She underwent surgical exploration and debridement with drainage of purulence from the medial wall of the orbit. Histological examination again showed granulomatous inflammation with hyphae, which were not prominently septated. The organism initially grew on Sabouraud's agar. Subculture to Czapek Dox agar produced the structures seen in Fig. 1 after 5 weeks of incubation.
Macroscopic view of the culture plate after incubation on Czapek Dox agar (top left), microscopic view of the organism (top right), and hematoxylin and eosin stain of debrided material at ×60 showing granulomatous inflammation associated with structures (arrows) in giant cells (bottom).
For answer and discussion, see https://doi.org/10.1128/JCM.00510-16 in this issue.
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