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Clinical Problem Solving: Pathology |

Pathology Quiz Case 1

Jocelyn S. Posthumus, MD; Mark S. Schneyer, MD
Arch Otolaryngol Head Neck Surg. 2011;137(10):1043. doi:10.1001/archoto.2011.144-a.
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A 29-year-old man with an unremarkable medical history presented to the otolaryngology clinic with a 6-month history of progressively worsening left-sided nasal obstruction and pain. Over the 15 days before presentation, he complained of daily epistaxis with associated yellow drainage. His sense of smell remained intact. He was originally from Guatemala but had moved to the United States about 10 years earlier.

Physical examination revealed an obstructive fibrous-appearing soft-tissue mass filling the left nasal cavity and deforming the left middle third of the nose. Nasal endoscopy demonstrated a thick, nodular mass with overlying fibrinous debris nearly occluding the left nasal cavity as well as a smaller fibrous mass located along the central septum on the right. Computed tomography showed a large soft-tissue mass in the left nasal cavity that appeared to emanate from the lateral nasal wall, without any evidence of bone erosion (Figure 1). Microscopic examination of a biopsy specimen showed mucosal ulceration, with the submucosa expanded by a population of epithelioid cells with abundant foamy cytoplasm (Figure 2). On immunohistochemical stains, these cells were negative for cytokeratin but positive for the histiocytic marker CD68 (Figure 3). Gomori methenamine silver, acid-fast, Fite, and Brown-Hopps Gram stains were negative for microorganisms. A Warthin-Starry silver stain, however, was notable for abundant intracytoplasmic bacilli (Figure 4).

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