it presents as a vascular , friable , sessile , or pedunculated mass usually arising from the nasal mucosa . the entry of the organism into the host is postulated to be via traumatized epithelium though in rare cases of dissemination a hematogenous spread may occur . ocular sites of infection are palpebral and bulbar conjunctiva , lacrimal sac , canaliculi , and the sclera . scleral melting associated with conjunctival lesions has resulted in staphylomatous protrusion of uveal tissue requiring tectonic graft . this is a report of conjunctival rhinosporidiosis in an immunocompromised patient who was on oral dapsone for disseminated rhinosporidiosis and highly active antiretroviral therapy ( haart ) for human immunodeficiency virus ( hiv ) infection . a 44-year - old male presented in 2012 with swelling on the undersurface of the right upper eye lid for 6 months . he was diagnosed elsewhere in 1998 to have rhinosporidiosis and was started on oral dapsone 100 mg twice daily . in spite of good compliance with dapsone therapy , he developed multiple recurrent cutaneous lesions requiring repeated excisions . in 2001 , while on treatment for disseminated rhinisporidiosis , he was tested seropositive for hiv . he had been on haart since 2004 and was compliant with treatment . at the time of presentation to us , he had multiple nodular lesions over the face , trunk , and extremities with cd4 + t - cell levels of 260 cells/l . on ocular examination , eversion of the upper eyelid showed a pedunculated friable conjunctival lesion in the right upper tarsal conjunctiva with white spherules over the lesion [ figure 1 ] . everted upper lid photograph showing sessile cystic lesion from the upper palpebral conjunctiva with superficial white spherules computerized tomography ( ct ) scan of the paranasal sinuses showed a polypoidal mass filling the left nasal cavity . also seen were a polypoidal mass in the oropharynx , and few cutaneous and subcutaneous lesions [ figure 2 ] . endoscopic excision biopsy of the mass confirmed the diagnosis of rhinosporidiosis [ figure 3 ] . chest x - ray , ultrasound abdomen , and ct brain were normal and did not reveal more lesions . contrast - enhanced computerized tomography at the level of nasopharynx ( a ) and oropharynx ( b ) showing a large polypoidal moderately enhancing mass filling up and expanding the left nasal cavity ( arrow ) , extending up to the choana posteriorly and into the vestibule anteriorly ( double arrows ) . small nodular cutaneous lesion in the right cheek ( curved arrow ) , subcutaneous lesions in the left parotid region ( long thin arrows ) , and a polypoidal mass in the oropharynx ( * ) are also seen thick - walled sporangia containing endospores associated with mixed inflammatory reaction , ( h and e , 200 ) excision biopsy of the conjunctival mass showed multiple thick - walled , variable - sized sporangia containing endospores within the subepithelium with inflammatory response thus confirming the diagnosis of conjunctival rhinosporidiosis . as he had developed recurrence even with good compliance to dapsone treatment , he was advised multidrug therapy with systemic cycloserine ( 250 mg thrice daily ) and ketoconazole ( 400 mg twice daily ) along with haart and dapsone . rhinosporidiosis is an infection of the mucous membranes manifesting as a polypoidal vascular friable mass . the common presentations are in the form of a nasopharyngeal mass ( 70% ) or an ocular lesion ( 15% ) . it is endemic in asia and africa , and 90% of the reported cases are from india . the mode of transmission is believed to be from the natural aquatic habitat through traumatized nasal mucosa . in rare cases of dissemination , a hematogenous spread has been postulated . the disease progresses with local replication of microcysts and is associated with hyperplastic growth of host tissue and localized immune response . rhinosporidosis presents as a tumor - like friable , vascularized , polypoid , hyperplastic wart - like mass that may be pedunculated or sessile and bleeds easily . the surface shows tiny white spots which are due to the underlying mature sporangia beneath the layer of the epithelium . diagnosis of rhinosporidiosis can be made by aspiration cytology and examination of the aspirated material with gomori methenamine silver and periodic acid  schiff stain . however , definitive diagnosis is by histopathology of biopsied tissues and identification of the pathogen in various stages of maturation . it has a mature stage of sporangia consisting of large , thick - walled spherical structures , and smaller daughter cells named endospores can be seen with fungal and routine hematoxylin and eosin staining . transepidermal elimination of the sporangia at the surface of the epithelium with extrusion of the endospores has been reported which explains the occurrence of satellite lesions . r. seeberi can not be grown in culture , and this prevents the determination of the sensitivity of this organism to drugs . this has been overcome recently by mtt reduction method which assesses the viability of the endospores of r. seeberi . spontaneous regression has been noted , however , definitive treatment consists of surgical excision with cauterization of the base . the potential for recurrence increases if there is spillage of endospores from the adjacent traumatized mucosa . the rate of recurrence can be reduced by cauterization of base of the lesion or cryotherapy . dapsone acts by arresting maturation of sporangia and accelerating its degenerative changes . in our patient , conjunctival involvement was noted while he was already on dapsone , suggesting nonresponsiveness to the drug . have shown that 50% inhibitory concentration ( ic50 ) of cycloserine against rhinosporidiosis is 10 g / ml . ic50 of < 100 g / ml is considered as therapeutic efficiency and of the eight antimicrobial agents tested in humans , cycloserine had the least ic50 values . there are many reports in the literature on disseminated as well as conjunctival rhinosporidosis in patients from endemic areas . however , this is a rare report of conjunctival rhinosporidiosis , in an immunocompromised patient . in endemic regions , rhinosporidiosis should be considered in the differential diagnosis for conjunctival lesions in immunocompetent as well as immunocompromised patients .
rhinosporidiosis is a granulomatous infection of mucocutaneous tissue caused by rhinosporidium seeberi that most commonly occurs in the nasal cavity . 
 ocular rhinosporidiosis affects primarily the conjunctiva . 
 diagnosis of rhinosporidiosis is based on strong clinical suspicion and is confirmed by histopathological examination . 
 we report a rare case of conjunctival rhinosporidiosis in an immunocompromised patient ( human immunodeficiency virus ) with disseminated cutaneous rhinosporidiosis . a 44-year - old male presented with a swelling in the right upper eyelid for 6 months . 
 excision biopsy of the ocular lesion showed multiple thick - walled , variable - sized sporangia containing endospores within the subepithelium suggestive of rhinosporidiosis . 
 a multidrug regimen of systemic cycloserine , ketoconazole , and dapsone was administered to treat disseminated rhinosporidiosis , in addition to antiretroviral therapy . 
 there was good response with reduction in the swellings .