Infections of the nose and paranasal sinuses in adult patients with immunodeficiency

Evaluation and treatment of rhinosinusitis with primary antibody deficiency in adults: Evidence-based review with recommendations

BACKGROUND

There is clear evidence that the prevalence of primary antibody deficiency (PAD) is higher in patients with recurrent and chronic rhinosinusitis (CRS) than in the general population. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on rhinosinusitis with PAD, summarize the existing evidence, and provide recommendations on the evaluation and management of rhinosinusitis in patients with PAD.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through August 2022. Studies on the evaluation and management of rhinosinusitis in PAD patients were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on the evaluation and management principles for PAD were generated.

RESULTS

A total of 42 studies were included in this evidence-based review. These studies were evaluated on incidence of PAD in rhinosinusitis patients, incidence of rhinosinusitis in PAD patients, and on the different treatment modalities used and their outcome. The aggregate quality of evidence was varied across reviewed domains.

CONCLUSION

Based on the currently available evidence, PAD can occur in up to 50% of patients with recalcitrant CRS. Despite the presence of multiple studies addressing rhinosinusitis and PAD, the level of evidence supporting different treatment options continues to be lacking. Optimal management requires a multidisciplinary approach through collaboration with clinical immunology. There is need for higher-level studies that compare different treatments in patients with PAD and rhinosinusitis.

A novel method to standardise serum IgA measurements shows an increased prevalence of IgA deficiency in young children with recurrent respiratory tract infections

Objectives

While physicians are often confronted with immunoglobulin A (IgA) deficiency in children with recurrent infections, the clinical relevance of this finding is unclear. Large‐scale studies examining the significance of IgA deficiency in children are hampered by differences in techniques for measuring IgA and the physiological increase of IgA with age. Both result in a variety of reference values used for diagnosing IgA deficiency. We propose a new laboratory‐independent method to accurately compare IgA measurements in children of varying ages.

Methods

We present a method to standardise IgA values for age and laboratory differences. We applied this method to a multicentre case–control study of children under the age of seven suffering from recurrent respiratory tract infections (rRTI, cases) and children who had IgA measured as part of coeliac disease screening (controls). We defined IgA deficiency as serum IgA measurements < 2.5% for age‐specific reference values.

Results

We developed reference values for IgA for seven age groups and five different laboratory assays. Using these reference values, IgA measurements from 417 cases and 224 controls were standardised to compare groups. In children aged 2 years and older, IgA deficiency was observed in 2.9% (7/242) of cases and 0% (0/189) of controls (P = 0.02).

Conclusion

We present a method to compare IgA values in cohorts that vary in age and laboratory assay. This way, we showed that IgA deficiency was more prevalent in children with rRTI compared with controls. This implicates that IgA deficiency may be a clinically relevant condition, even in young children.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Allergic and Nonallergic Rhinitis. Classification and Pathogenesis: Part II. Nonallergic Rhinitis

Part I of this review classified and defined the causes of chronic rhinitis, describing in detail the etiology and pathophysiology of allergic rhinitis. Part II focuses on the nonallergic (non-IgE) causes of chronic rhinitis, concentrating on their clinical presentations, differential characteristics, and known or speculative pathophysiology. A comprehensive understanding of the allergic and nonallergic conditions associated with symptomatic rhinitis should aid the clinician in the appropriate diagnosis and treatment of patients with chronic rhinitis.

Primary immunodeficiency and recalcitrant chronic sinusitis: a systematic review

BACKGROUND

A subset of patients with chronic rhinosinusitis (CRS) has disease refractory to standard therapies. Primary immunodeficiency should be considered in this group. Past literature has demonstrated an association between immunodeficiency and chronic sinusitis.

METHODS

A systematic literature search was performed using OVID, MEDLINE, EMBASE, and Cochrane databases to identify English language papers containing original human data on subjects with primary immunodeficiency and chronic sinusitis. A total of 39 studies met inclusion criteria. Data was collected pertaining to immune dysfunction in patients with chronic sinusitis, the clinical workup for these patients, and the effectiveness of medical and surgical treatments. The studies were assessed to determine their level of evidence.

RESULTS

The majority of studies were supported by Level 4 evidence. Up to 50% of patients with recalcitrant CRS were found to have immune dysfunction. The most frequent primary immunodeficiencies studied were common variable immunodeficiency (CVID) and X-linked agammaglobulinemia (XLA). Common collected data included measurement of serum immunoglobulins and functional antibody responses. Treatments reviewed include immunoglobulin replacement, long-term antibiotics and endoscopic sinus surgery.

CONCLUSION

Patients with recalcitrant CRS should be evaluated for primary immunodeficiency. This should include as assessment of quantitative serum immunoglobulin levels as well as functional antibody responses. Medical therapy, particularly immunoglobulin replacement therapy, appears to be most effective when administered at high doses early in the disease course. The addition of surgery is less clearly supported, but may also provide benefit if performed early.

X‐Linked Agammaglobulinemia: A Survey of 33 Iranian Patients

In order to determine the clinical and laboratory features of X-linked agammaglobulinemia, the records of 33 male patients with XLA were reviewed during 22 years (1980-2002) in the Iranian referral center of primary immunodeficiency disorders. The patients' ages ranged from 20 to 360 months (median 113 months). The median age at the onset of the disease was 8 months and the median age of diagnosis was 48 months, with a median diagnosis delay of 33 months. Almost all of the patients presented common infectious diseases, which were: pneumonia, otitis, diarrhea, sinusitis, and arthritis. During the course of illness, infections in the respiratory tract, gastrointestinal tract, central nervous system, and musculoskeletal system were seen in 93.9%, 75.8%, 33.3%, and 21.2% of XLA patients, respectively. The most common complications of these patients were chronic infections in 75.8% of them, including: chronic otitis media, chronic sinusitis, chronic diarrhea, and bronchiectasis.

Immunoglobulins in nasal secretions of patients with allergic rhinitis and chronic rhinosinusitis

Allergic rhinitis and chronic rhinosinusitis are the most frequently encountered inflammatory reactions of the sinonasal mucosa. Nasal-associated lymphoid tissue has been suggested as an inductive site for humoral and cellular immune responses in the upper respiratory tract. Immunoglobulins are important elements in human adaptive immune responses and deficiencies of serum immunoglobulins may be associated with recurrent or refractory infections. However, the local humoral immune response to offending antigens in the nasal environment has not been well elucidated. To determine the levels of IgA and IgG subclasses antibodies in the nasal secretions of patients with allergic rhinitis and chronic rhinosinusitis, 25 patients with allergic rhinitis and 20 with chronic rhinosinusitis were included and their nasal secretions were collected to measure the levels of secretary IgA (sIgA), total IgA (tIgA), and IgG subclasses antibodies. There was a significant elevation of IgG(3) in the nasal secretions of patients with chronic rhinosinusitis. No difference was noted in the levels of sIgA, tIgA, IgG1, IgG2 and IgG4 among the three groups. The local defense mechanism of nose reacts to microorganisms and pathogenic antigens by inducing the adaptive humoral immune response to increase the amount of immunoglobulins, with IgG3 being the major up-regulated antibody.

ENT manifestations in Iranian patients with primary antibody deficiencies

OBJECTIVE

One hundred and nine patients with primary antibody deficiencies were selected in order to determine the frequency of ENT complications.

METHOD

Demographic information and ENT medical histories were collected for each patient. Duration of study for each patient was divided into two periods of before diagnosis and after diagnosis and the initiation of treatment.

RESULTS

Eighty-two of 109 patients (75.2 per cent) experienced ENT infections during the course of the disease (63: otitis media, 75: sinusitis and nine: mastoiditis). At the time of diagnosis, 52 (47.7 per cent) out of 109 patients presented with an ENT symptom. The frequencies of episodes were 27 for sinusitis and 25 for otitis media (one complicated with mastoiditis). After immunoglobulin replacement therapy the incidence of otitis media was reduced from 1.75 before treatment to 0.39 after treatment per patient per year (p = 0.008). The incidence of sinusitis also significantly decreased from 2.38 to 0.78 (p value = 0.011).

CONCLUSION

ENT infections are common medical problems in primary antibody deficiency patients. Persistent and recurrent ENT infections should be suspected as originating from a possible underlying immunodeficiency.

Clinical and immunological features of 65 Iranian patients with common variable immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunodeficiency disease characterized by hypogammaglobulinemia and recurrent bacterial infections. The records of 65 patients with CVID (37 males and 28 females) in the age range of 24 to 537 months were reviewed. By the year 2003, 11 patients had died and seven patients could not be located. The total follow-up period was 221 patient-years. The median diagnostic delay (time between onset and diagnosis) in our patient group was 60 months. At the time of diagnosis, the baseline serum immunoglobulin G (IgG), IgM, and IgA levels were below the level normal for the patients' age; the medians for this group were 120, 10, and 0 mg/dl, respectively. All of the patients presented with infectious diseases at the time of onset, the most common of which were otitis media, diarrhea, pneumonia, and sinusitis. Acute and recurrent infections were also found in almost all of the patients, particularly involving respiratory and gastrointestinal systems. The most common infections, before diagnosis and during follow-up, were pneumonia, acute diarrhea, acute sinusitis, and otitis media. CVID should be considered in any patient with a history of recurrent infections and decreased levels of all serum immunoglobulin isotypes.

Otolaryngologic manifestations of immunodeficiency

Otolaryngologists are frequently consulted to manage infectious and noninfectious complications of immune deficiency. Although defects of host defense and recurrent or severe infections are the most obvious manifestations of immune deficiency, patients are often at increased risk for autoimmune and malignant disease as well. Knowledge of primary and acquired immune deficiencies will facilitate appropriate identification, treatment, and referral of patients with these defects. When immunodeficiency is known or suspected, it is particularly important to have a high index of suspicion for unusual or severe manifestations of infection, to have a low threshold for obtaining imaging to aid in diagnosis, and to treat infections for longer periods of time with higher doses of antibiotic. Surgery may be required for definitive treatment of infections that do not respond to medical therapy and for management of complications of infectious disease

Investigation for immunodeficiency in patients with recurrent ENT infections

Patients suffering with primary immunodeficiency frequently present to ear, nose, and throat (ENT) clinics, but the diagnosis is rarely made at this time. Early diagnosis of these patients would help to prevent morbidity and even mortality. Normal results from a simple panel of blood tests will exclude the commonest immune deficiencies. An abnormal result from these tests, or a strong suspicion despite normal initial testing, should prompt discussion with an immunologist.

Immunologic Defects in Patients with Chronic Recurrent Sinusitis: Diagnosis and Management

Twenty patients with chronic refractory sinusitis or rhinitis were identified to have immune defects on the basis of total immunoglobulin level, immunoglobulin G subclass, and vaccine response. Eight patients were immunoglobulin A deficient, five had low immunoglobulin levels with vaccine hyporesponse, and four had low immunoglobulin levels with normal vaccine responses. Three subjects showed isolated immunoglobulin G1 deficiency. Demographic variables such as age, sex, infection pattern, and any other related disorders were studied retrospectively, which may have contributed to the diagnosis. An immunologic screen was essential for the diagnosis of immunodeficiency in these patients. Treatment options included prophylactic antibiotics, management of associated allergies, functional endoscopic sinus surgery, and replacement therapy with immunoglobulin in selected patients.

Does allergic rhinitis predispose to sinusitis?

The relationship between allergic rhinitis and sinusitis is reviewed with regard to seasonal as well as perennial and fungal sinusitis. There seems to be some association between allergic processes in the nose and inflammation in the sinus mucosa but the available data are, to some extent, contradictory. Thus, the causative role of allergy in sinusitis is not clear. Prospective studies to further elucidate the influence of allergic inflammation in the pathogenesis of sinusitis are highly warranted.

Chronic sinusitis: clinical and pathophysiological aspects

Sinusitis can be defined as inflammation of the paranasal sinus mucosa. However, the definition of chronic sinusitis is not yet fully established. As chronic sinusitis occurs both on an infectious and non-infectious basis there are many symptoms, local as well as general, from the upper respiratory tract. It is generally agreed that the time aspect of the disease is important. Long-term symptoms, i.e. more than 3 months, and objective findings of mucosal inflammation are criteria for chronic sinusitis. In clinical practice it is also important to realize that mucosal changes usually persist for at least 8 weeks after the treatment of an acute infection. Interest has lately been focused on local sinusal inflammation, especially on the inflammatory cells whose immunoactive products seem to keep inflammation ongoing even after the infection is cured. It is not clear to which extent the mucosal damage, with granulation tissue, polyp formation and fibrosis, is reversible. In chronic sinusitis, the ostial function is disturbed, especially in patients with nasal polyposis. This function must be re-established, but it is still uncertain whether obstruction in the osteomeatal complex is primary or secondary to other factors. Further research into local immunological factors and analysis of the development of special local tissue pathology in sinusitis is necessary in order to be able to establish exactly why acute sinusitis does not resolve but turns into a chronic inflammatory disease.

Secretion from gland and goblet cells in infected sinuses

The number of goblet cells in the normal mucosa in the paranasal sinuses is comparable to that in the nasal mucosa. There are relatively few mucosal glands in the sinuses. In recent years, the maxillary sinus of the rabbit has been used for experimental studies. After induced infections, the number of goblet cells increases. In pneumococcal sinusitis, the number reaches a peak after 3 weeks and then declines. In sinusitis induced by St. aureus and the anaerobic bacteria B. fragilis, the number is more progressive over time and persistent during 12 weeks. The number of glands shows no hyperplasia, but occasionally atypical glands can be found. In patients with chronic sinusitis, the number of goblet cells is usually not affected but the number of glands increases, and the glands usually have a pathological shape. A decreased ciliary beating frequency correlates well with an increase in number of goblet cells. However, 75% of patients with chronic sinusitis have a normal frequency. When performing studies in patients with sinusitis one should be aware of the dynamic course of the disease and the difficulty in evaluating single mucosal biopsies.

Sinus computerized tomography in primary hypogammaglobulinaemia

Thirteen patients suffering from primary hypogammaglobulinaemia receiving intravenous immunoglobulin replacement therapy underwent computerized tomography of the paranasal sinuses. The CT scans were evaluated and related to clinical data from the patients, who were selected for study on the basis of having symptoms of rhinosinusitis. The scans varied from normal to demonstrating widespread sinus abnormality. There was no relationship between the scan findings and duration of ENT symptoms, range of current symptoms, or the interval between the onset of ENT symptoms and the start of intravenous immunoglobulin replacement therapy. It is nevertheless possible that prompt institution of replacement therapy, after correct diagnosis early in the course of the disease, may prevent the development of sinus disease refractory to such treatment.

IgA and IgG subclass deficiency in a poor population in a developing country

The levels of IgG, IgG subclasses, IgM and IgA were determined in serum from 17 patients with IgA deficiency and severe or frequent infections, allergy and/or autoimmunity (median age 7 years, range 2-19), 11 healthy IgA-deficient adults and 35 controls (median age 7 years, range 2-19). In serum from all groups IgG, IgM and IgA antibodies were determined against beta-lactoglobulin, E. coli O antigens and poliovirus type 1 antigen. In saliva of 15 IgA-deficient patients and 12 of the controls IgG, IgM and secretory component-carrying antibodies against E. coli O antigens and poliovirus type 1 were determined. The majority of the studied individuals lived under poor socio-economic conditions in Brazil, with consequent heavy microbial exposure. One IgA-deficient patient with rheumatoid arthritis also had IgG2 deficiency but no infectious problems. Four out of the 35 controls without any obvious infectious problems were found with IgA or IgG subclass deficiency. One of the 11 healthy IgA-deficient adults was low in the IgG2 subclass, one in IgG1 and one in IgG3. Those with symptomatic IgA deficiency had significantly higher serum IgG than the controls, especially in the age group 6-11 years. This latter group also had significantly increased serum IgG1 and IgG2 levels when compared with the age-matched controls. Salivary IgM antibodies to E. coli and poliovirus antigens were significantly higher among the symptomatic IgA-deficient individuals than among the controls. It is not clear at present whether these increased Ig levels are secondary to frequent infections and/or part of mechanisms that may compensate for the IgA deficiency.

Medical and surgical management of sinusitis in adults

Sinusitis may be caused by bacteria, viruses, or trauma and may appear in immunosuppressive settings. Acute sinusitis is most commonly diagnosed on the basis of pain and discharge; endoscopic or fiberoptic examination may be helpful in less obvious cases. Radiography can identify maxillary, frontal, and sphenoid sinusitis; transillumination can be used if radiography is undesirable. Culture and Gram stains may help determine the appropriate antibiotic therapy. Surgery may be necessary if the frontal or sphenoid sinus is involved, or if ethmoiditis is progressing to orbital cellulitis. In chronic sinusitis, endoscopic examination and computed tomographic scanning are useful for diagnosis. Chronic sinusitis may be associated with airway disease, aspirin allergy, and such diseases as cystic fibrosis. Antibiotic therapy that acts against anaerobes and beta-lactamase-producing organisms should be chosen. Surgical treatment includes intranasal and external ethmoidectomy, antrostomy, and, on occasion, obliteration of the involved cavity.

Penetration of administered IgG into the maxillary sinus and long-term clinical effects of intravenous immunoglobulin replacement therapy on sinusitis in primary hypogammaglobulinaemia

The influence of long-term intravenous immunoglobulin (i.v. IgG) replacement therapy on the clinical course of chronic sinusitis in patients with primary hypogammaglobulinaemia has not previously been reported. We have analysed the efficacy of i.v. IgG therapy and the penetration of administered i.v. IgG into the maxillary sinus. Seventeen patients with primary hypogammaglobulinaemia received i.v. IgG replacement therapy to maintain pre-infusion serum IgG concentrations above 4 g/l for periods of 12 to 58 (mean 36.7) months. Cases with established chronic sinusitis prior to therapy did not have symptomatic or radiological improvement at this dose, although no sinusitis developed de-novo in the 3 previously unaffected patients. The administered IgG penetrated into maxillary sinus antral lavage fluid in 3 patients from whom secretions were obtained at antroscopy. This indicates that poor clinical responses are not due to lack of penetration of antibodies to the required sites of action. Larger doses of i.v. IgG may be more effective in this situation, but the addition of antibiotics at high dosage may be a more economical therapeutic alternative. These findings highlight the importance of diagnosis of hypogammaglobulinaemia by measurement of serum IgG concentrations in patients who suffer from recurrent sinusitis, as the early institution of i.v. IgG therapy may prevent the development of sinusitis refractory to i.v. IgG therapy.

Humoral immunity in nasal mucosa of patients with common variable immunodeficiency

Humoral immunodeficiency, as reflected by the low serum immunoglobulin (Ig) concentrations in adult patients with common variable immunodeficiency (CVID), was even more severely expressed at the B-cell level in their nasal mucosa. No Ig-producing cells could be detected by immunohistochemistry in 11 of 19 mucosal specimens. The epithelial distribution of secretory component (SC) was normal in all specimens, but a sign of SC-dependent IgM transport was seen in only three. Epithelial IgA was completely lacking. All patients had had recurrent lower respiratory tract infections and 16 had recurrent or chronic infections of the upper respiratory tract. A previous report indicated that the intestinal mucosa is a privileged site for maturation of B cells in patients with CVID; the present study shows that this does not hold true for the nasal mucosa. This difference in B-cell maturation may in part explain the preferential susceptibility to infections in the respiratory tract of patients with CVID.