\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Long-standing laryngeal rhinoscleroma with rare Mikulicz cells}



\author[1]{Raheem  Peerani}%
\author[1]{Manish Shah}%
\author[1]{Brian Minnema}%
\author[2]{Hasan Ghaffar}%
\author[3]{Runjan Chetty}%
\author[4]{Jan Delabie}%
\author[4]{Bayardo Perez-Ordonez}%
\author[4]{Daniel Xia}%
\affil[1]{North York General Hospital}%
\affil[2]{St Michael's Hospital}%
\affil[3]{Diagnexia}%
\affil[4]{University Health Network}%


\vspace{-1em}



  
  \date{May 27, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Rhinoscleroma is a granulomatous infectious disease that typically
affects the nasopharynx and upper respiratory tract. Non-endemic (e.g.,
North American) and laryngeal cases are rare. This case highlights the
importance of pathognomonic Mikulicz cells for diagnosis.%
\end{abstract}%



\sloppy


\textbf{Title:} Long-standing laryngeal rhinoscleroma with rare Mikulicz
cells

\textbf{Authors:} Raheem Peerani\textsuperscript{1,2}, Manish
Shah\textsuperscript{1,3}, Brian Minnema\textsuperscript{1}, Hasan
Ghaffar\textsuperscript{2,4}, Runjan Chetty\textsuperscript{5}, Jan
Delabie\textsuperscript{2,7}, Bayardo
Perez-Ordonez\textsuperscript{2,6}, and Daniel Xia\textsuperscript{2,7*}

\textbf{Affiliations:}

\begin{enumerate}
\tightlist
\item
  North York General Hospital, Toronto, ON
\item
  Department of Laboratory Medicine and Pathobiology, University of
  Toronto, Toronto, ON
\item
  Department of Otolaryngology -- Head and Neck Surgery, University of
  Toronto, Toronto, ON
\item
  Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
\item
  Diagnexia
\item
  Division of Anatomical Pathology, University Health Network, Toronto,
  ON
\item
  Division of Hematopathology and Transfusion Medicine, University
  Health Network, Toronto, ON
\end{enumerate}

\textbf{*Corresponding author:}

Daniel Xia Division of Hematopathology and Transfusion Medicine
University Health Network 200 Elizabeth Street Toronto, Ontario M5G 2C4
Email: Daniel.xia@uhn.ca Phone: 416-340-4800 x4734

\textbf{Consent information:} Written informed consent was obtained from
the patient to publish this report in accordance with the journal's
patient consent policy.

\textbf{Abstract:} Rhinoscleroma is a granulomatous infectious disease
that typically affects the nasopharynx and upper respiratory tract.
Non-endemic (e.g., North American) and laryngeal cases are rare. This
case highlights the importance of pathognomonic Mikulicz cells for
diagnosis.

A man in his early-50s presented with worsening stridor,
shortness-of-breath, and hoarseness over 2 years. Originally from
northwestern South America, he reported with similar symptoms 7 years
ago, but work-up did not produce a specific diagnosis. For this
presentation, a large obstructing mass on the laryngeal surface of the
epiglottis was identified on emergency laryngoscopy that prevented
visualization of the vocal cords and lower respiratory tract (Figure 1).
Tracheostomy was performed. Biopsies showed squamous mucosa with
submucosal fibrosis and a dense infiltrate, composed mostly of plasma
cells and plasmacytoid lymphocytes, with rare/scattered macrophages
containing intracellular gram-negative rods (Mikulicz cells; Figure 1)
--suggesting a diagnosis of rhinoscleroma\textsuperscript{1,2}.

Confirmatory cultures showed \emph{Klebsiella ozaenae} . Subsequent
ciprofloxacin led to improved stridor, near-complete regression of the
supraglottic mass, with improved vocal cord mobility and patent
subglottis; corking trials were carried out with the tracheostomy
tube,~and the patient was safely decannulated.~ At 8-month follow-up,
the laryngeal exam remains stable with no evidence of
recurrence/regrowth.

\textbf{Authorship list:} RP, HG, RC, JD, BP-O, and DX analyzed the
pathology. MS collected and analyzed the clinical data. BM analyzed the
microbiology. All authors drafted, reviewed, and approved the
manuscript.

\textbf{Acknowledgments:} None

\textbf{Conflict of interest statement:} The authors do not have
relevant disclosures or conflicts of interest to report.

\textbf{Consent:} Written informed consent was obtained from the patient
to publish this report in accordance with the journal's patient consent
policy.

\textbf{References:}

1 Umphress B, Raparia K. Rhinoscleroma. Arch Pathol Lab Med
2018;142:1533--1536.

2 Awad O, Zaky E, Talaat M. Correlation Between Nasal and Laryngeal
Lesions of Rhinoscleroma in Patients of Upper Egypt. J Voice 2020.
doi:10.1016/j.jvoice.2020.07.017.

\textbf{Figure 1. Laryngeal mass in a gentleman in his early 50s.} Top
left. Direct laryngoscopic image of supraglottic larynx showing an
irregular ulcerative mass. Top right. Axial CT images taken after the
patient's tracheostomy was completed.~ Emphysematous changes in the soft
tissue are the result of the surgical procedure.~ Nasogastric tube can
be seen in the esophagus.~There is a mass visible in the supraglottic
larynx (arrows) that is causing narrowing of the airway.~ Bottom. On
microscopy, H\&E (left) and Gram (right) stains show rare Mikulicz cells
containing intracellular bacteria (gram negative rods on the Gram
stain).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure,-v3/figure,-v3}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

