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CORRESPONDENCE
Year : 2021  |  Volume : 66  |  Issue : 4  |  Page : 409-411
Penile Rhinoscleroma Masquerading as Penile Malignancy: A Case of Mistaken Identity


1 Department of Dermatology, Venereology and Leprosy, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
2 Department of Dermatology, Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication17-Sep-2021

Correspondence Address:
Indrashis Podder
Department of Dermatology, Venereology and Leprosy, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_61_17

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How to cite this article:
Podder I, Gharami RC. Penile Rhinoscleroma Masquerading as Penile Malignancy: A Case of Mistaken Identity. Indian J Dermatol 2021;66:409-11

How to cite this URL:
Podder I, Gharami RC. Penile Rhinoscleroma Masquerading as Penile Malignancy: A Case of Mistaken Identity. Indian J Dermatol [serial online] 2021 [cited 2021 Dec 3];66:409-11. Available from: https://www.e-ijd.org/text.asp?2021/66/4/409/326130




Sir,

Rhinoscleroma is a chronic, inflammatory, granulomatous condition caused by Klebsiella pneumoniae sp. rhinoscleromatis, primarily affecting the upper respiratory tract and adjacent structures, namely, nose, pharynx, and larynx.[1] We report a case of penile rhinoscleroma in a 48-year-old man, which was initially misdiagnosed as malignancy. Proper diagnosis and prompt treatment helped the patient avoid unnecessary penile amputation.


   Case Report Top


A 48-year-old man was presented to us with multiple asymptomatic swellings over the tip of his glans penis for the last 3 months with occasional watery discharge. Initially, there was single swelling which gradually increased in size. In the course of time, smaller swellings developed in the vicinity which coalesced together to form a hard plaque. The patient had worked in a dye industry for the last three decades. Family history and drug history were unremarkable. There was no history of travel to any endemic region. Physical and systemic examination revealed no abnormality. His blood biochemistry was within normal limits. Dermatological examination revealed stony hard subepidermal nodules, some of which have coalesced to form a hard, indurated, sclerotic plaque of about 3.5 × 2 cm in dimension. The surface was moist with red speckled appearance [Figure 1]. The patient reported occasional watery discharge without any history of bleeding or ulceration. Lesional biopsy and staining with hematoxylin and eosin (H and E) showed sclerotic epidermis with abundant plasma cells and lymphocytes in the dermis along with fibrosis [Figure 2]. Few foamy histiocytes were also noted (Mikulicz cells) [Figure 3]. There was no lymphadenopathy. Hairs, nails, and other mucosae were spared. The patient was prescribed ciprofloxacin 500 mg twice daily and advised follow-up after 3 months.
Figure 1: Hard nodules and sclerotic plaque at the tip of glans penis

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Figure 2: Numerous lymphocytes, plasma cells, and Mikulicz cells in the dermis along with fibrosis (H&E, 100×)

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Figure 3: Close-up showing plasma cells (thin arrow) and Mickuliz cells (thick arrow) in the dermis (H&E, 400×)

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   Discussion Top


Rhinoscleroma, caused by K. pneumoniae sp. rhinoscleromatis, is a chronic, inflammatory granulomatous condition primarily affecting the upper and lower respiratory tract (nasal mucosa, pharynx, and larynx).[1] The name rhinoscleroma was first used in 1870 by Von Hebra and Kaposi when describing a nasal lesion mimicking sarcoma.[2] The disease affects both sexes with female predominance[3], most commonly during the third and fourth decades. Our patient was a male in his fifth decade. Although this disease has been reported to be endemic in South America, increased incidence is also being reported from southern India.[4] Very few cases have been reported from eastern India.

This condition is often characterized by sclerosis and deformity of the affected part (upper and lower respiratory tract), often resulting in death due to upper airway obstruction. The disease begins insidiously with increased nasal secretion (nasal catarrh), gradually leading to the formation of hard subepidermal nodules and sclerotic plaques. Our patient was presented with hard subepidermal nodules and sclerotic plaques involving his glans penis with occasional watery discharge. In our patient, rhinoscleroma was in the glans penis, probably the first report of its occurrence outside the respiratory tract.

The diagnostic histopathology of rhinoscleroma showed epidermal hyperplasia along with abundant plasma cells and lymphocytes in the dermis. Occasionally, foamy macrophages were visible containing the bacilli called Mickuliz cells (larger in size) and Russell bodies (degenerated plasma cells). Our case also showed similar findings on H and E staining. Intracytoplasmic bacilli can be best demonstrated using Periodic acid-Schiff (PAS), Giemsa, or Warthin silvery stain or by culture. However, these facilities were not available at our center.

The clinicopathologic differentials of our case were syphilitic gumma (clean looking indurated ulcer with inguinal lymphadenopathy), malignancy (stony hard, indurated mass with lyphadenopathy and characteristic histology showing dysplasia), keloid (dry lesion; no discharge), sarcoidosis (noncaseating granulomas), hypertrophic forms of tuberculosis (caseating granuloma), and rhinosporidiosis (sporangia of Rhinosporiduim seeberi). Typical histological findings clinched our case to be rhinoscleroma.

Rhinoscleroma has been reported to be successfully treated with fluoroquinolones for at least 3 months to prevent recurrence. Our patient was also prescribed ciprofloxacin for 3 months. Surgery may be needed rarely if there is much deformity of the affected part(s).


   Conclusion Top


Our case has been reported to highlight the importance of astute clinical examination and histopathologic examination (HPE) to arrive at the correct diagnosis. Our patient had been initially diagnosed with penile malignancy and advised for penile amputation. The timely diagnosis and proper treatment saved him from an impending catastrophe. This is probably the first report of penile rhinoscleroma in English literature, which should be considered a probable differential in such clinical scenario.

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.



 
   References Top

1.
James WD, Elson D, Berger T. Bacterial infections. Andrews Diseases of The Skin. 11th ed. Saunders Elsevier (UK); 2011. p. 272-3.  Back to cited text no. 1
    
2.
Abalkhail A, Satti MB, Uthman MA, Al Hilli F, Darwish A, Satir A. Rhinoscleroma: a clinicopathological study from the Gulf region. Singapore Med J. 2007;48:148-51.  Back to cited text no. 2
    
3.
Ahmed AR, El-Badawy ZH, Mohamed IR, Abdelhameed WA. Rhinoscleroma: A detailed histopathological diagnostic insight. Int J Clin Exp Pathol 2015;8:8438-45.  Back to cited text no. 3
    
4.
Bhagyalakshmi A, Rao CV, Krishna KT, Kartheek BVS. Rhinoscleroma: A case report. Int J Case Rep Images 2014;5:868-72.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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