28_02p780g

Case Report
Blowing a nose black and blue
Matteo Gelardi, Maria Luisa Fiorella, Eustachio Tarasco, Giovanni Passalacqua, Francesco Porcelli
Lancet 2009; 373: 780
In June, 2006, a 32 year-old woman, working as an architect results. Nasal smears showed no fungi, but we observed Department of Ophthalmology at the archaeological site of Pompeii, noticed that her nose
black, amorphous bodies, which we interpreted as and Otolaryngology was blocked, especially the right nostril. When she blew cellular debris (figure). We suggested that the patient
(M Gelardi MD, M L Fiorella MD), her nose, the mucus was black. A few days later, she clean her nose and sinuses with a douche, which allowed
and Department of Biology
and Agro-Forestry and developed a dry cough, and intermittent fever. Her general
a continuous flow of saline through the nose. During the Environmental Chemistry practitioner referred her to an otolaryngologist. Nasal
first washing, a small insect was expelled from the nostril; (E Tarasco BS, F Porcelli BS), examination showed no abnormality, other than mild immediate symptomatic improvement ensued. The
University of Bari, Italy; and septal deviation. Skin-prick tests for allergy gave negative patient informed us, and the insect was collected, and
Department of Internal
Medicine, University of Genoa, results, as did nasal smears for bacteria and fungi; CT of
identified as Clogmia albipunctata [=Telmatoscopus Italy (G Passalacqua MD)
the sinuses showed nothing of note. Nonetheless, the albipunctatus]. We deduced that the amorphous black Correspondence to: patient’s nasal blockage and rhinorrhoea worsened; she objects were insect faeces. The fever, cough, and nasal Dr Giovanni Passalacqua, Allergy had occasional fever spikes, and was referred to an obstruction completely resolved within a few days— & Respiratory Diseases, infectious-diseases specialist. Chest radiography and however, the black discharge continued, although, given Medicine, Padiglione Maragliano, pulmonary function tests gave normal results; blood tests the mucociliary clearance rate, we had expected it to L go R Benzi 10, 16132 Genoa, showed a high concentration of C-reactive protein, mild disappear in about 2 days. The patient became depressed Italy neutrophilia and, although no fungal hyphae had been and frustrated, and feared that she had other insects in [email protected] found in nasal smears, antibodies to aspergillus. Oral her nose, although this possibility was excluded by CT
itraconazole (100 mg daily) was therefore prescribed; and MRI. During a consultation, we noticed that she 2 months later, no benefit had been observed. wore eyeliner. She confirmed that she sometimes used a We saw the patient in September, 2007. Nasal endoscopy, kohl pencil. We asked her to stop. The black secretion CT of the sinuses, and allergy tests again gave negative disappeared within 2 days. We realised that kohl, mixed with tears, had been passing though an abnormally patent nasolacrimal duct, and produced the black- pigmented bodies previously identified as insect faeces. When the patient wore blue eyeliner, blue nasal secretions appeared.
Our lessons from this event? When usual diagnoses for common illnesses such as rhinitis1,2 are excluded, reflect on underlying mechanisms, and consider the (nearly) impossible. In this case, the nasolacrimal duct was, unusually, wide enough to host an insect, and to allow kohl fragments to enter the nose. What caused the systemic inflammation? The patient did not have conjunctivitis, although the conjunctiva was in direct contact with her eyeliner. Moreover, the inflammatory symptoms stopped after the fly was ejected. We therefore blame the fly.3 We note, however, that commercial kohl can contain more than 25 different substances, some of which can provoke allergy; health problems have been caused by kohl containing lead. We do not wish to issue a blanket warning against kohl. Ingredients of kohl vary markedly. In south Asia, and across much of the Muslim world, traditional recipes are regarded as medicinal. Much-feared Pashtun warriors historically applied kohl
before surging into battle.
Acknowledgements
We thank Prof Giovanni Salamanna DIP TE RIS, University of Genova,
for insect identification.
Contributors
All authors contributed to clinical management and discussion of the case, and to the preparation and revision of this report. All have seen Figure: What is coming out of the nose?
(A) Nasal smear, showing small black objects; magnification ×1000. References
(B) C albipunctata, a large two-winged object.
www.thelancet.com Vol 373 February 28, 2009
€$£¥∆Ωµ∏π∑Ωαβχδεγηκλμτ†‡ ∞�姶√+−±×÷≈<>≤≥↔←↑→↓ Bousquet J, Khaltaev N, Cruz AA, et al. Allergic rhinitis and its impact on asthma (ARIA) 2008 update. Al ergy 2008; (suppl 63) 86: 8–160.
Thomas M, Yawn BP, Price D, Lund V, Mullol J, Fokkens W. EPOS primary care guidelines: European position paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps 2007—a summary. Prim Care Respir J 2008; 17: 79–89.
Nwvill EM, Basson PA, Schoonraad JH, Swanepoel K. A case of nasal myiasis caused by the larvae of Telematoscopus albipunctatus (Williston) 1893 (Diptera: Psychodidae). S Afr Med J 1969; 43: 512–14.

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