Aspergillus sinusitis in cancer patients

Allergy and Fungal Screens in Chronic Sinusitis

Thirty-three patients with chronic sinusitis severe enough to warrant surgery were prospectively screened for atopic disease and fungal sensitivity by history, total IgE levels, an allergen-specific IgE screen panel and fungal IgE levels. Total IgE was elevated in 10 of 31 patients measured. A positive “screen” panel (milk, Candida, house dust, white ash, timothy grass, ragweed) was noted in 57.5%. Fungal sensitivity to one or more of the following molds, Aspergillus, Mucor, Alternaria, Candida, Cladosporium, Penicillin notatum, Helminthosporium, or Curvularia, was noted in 51.5%. Seventeen patients had both positive atopic and fungal screens. All those with positive fungal screens also had positive atopic screens. The predictive value of allergy screens may be useful when the incidence in the population to be tested is 50% or greater. This study suggests that use of allergy screens and/or screens for fungal IgE may have a predictive value of 90% or greater with chronic sinus disease. Measurements of total IgE do not appear to add useful information and have a low predictive value as a test. Preliminary conclusions suggest that the incidence of atopy and elevated fungal IgE is high in patients with chronic sinusitis. Screens for allergies and fungal IgE may be useful to identify patients for further evaluation.

Impact of Surgical Treatment on Paranasal Fungal Infections in Bone Marrow Transplant Patients

Invasive fungal sinusitis can develop in immunosuppressed patients. A more complex problem is immunosuppressed patients who have undergone bone marrow transplantation. For a prolonged period, they are both neutropenic and thrombocytopenic. Survival in these patients is poor, and the role for extensive surgical intervention for sinus disease has to be weighed against the risk and the potential that this is a systemic disease. Between January 1983 and June 1993, 29 bone marrow transplant recipients with documented invasive fungal infections of the sinuses and paranasal tissues required surgical intervention. This represents 1.7% of the total 1692 bone marrow transplants performed. There were 22 allogeneic, 6 autologous, and 3 unrelated donor transplants, with two patients receiving two separate grafts. Underlying diseases included 24 hematologic malignancies and 5 other disorders, including 1 aplastic anemia and 1 solid tumor. The mortality rate from the initial fungal infection was 62%. Twenty-seven percent resolved the initial infections but subsequently died of other causes. All patients received medical management, such as amphotericin, rifampin, and colony-stimulating factors, in addition to surgical intervention. Surgical management ranged from minimally invasive procedures to extensive resections including medial maxillectomies. Sixty-one percent of the patients who died of the initial infection had undergone extensive surgical procedures versus 55% of those who resolved the infection. Recovery of neutrophil counts was required to clear the infection but did not necessarily predict a good outcome because 50% of those who died of the infection had experienced neutrophil recovery. White blood cell counts at the time of surgery were not significantly different between the two groups. Prognosis was poor when cranial and orbital involvement and/or bony erosion occurred.

Treatment of invasive fungal infections in cancer patients-updated recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO)

The Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) here presents its updated recommendations for the treatment of documented fungal infections. Invasive fungal infections are a main cause of morbidity and mortality in cancer patients undergoing intensive chemotherapy regimens. In recent years, new antifungal agents have been licensed, and agents already approved have been studied in new indications. The choice of the most appropriate antifungal treatment depends on the fungal species suspected or identified, the patient's risk factors (e.g., length and depth of neutropenia), and the expected side effects. This guideline reviews the clinical studies that served as a basis for the following recommendations. All recommendations including the levels of evidence are summarized in tables to give the reader rapid access to the information.

Aspergillus flavus: an emerging non-fumigatus Aspergillus species of significance

Invasive aspergillosis is rare in immunocompetent people but contributes to significant morbidity and mortality in immunosuppressed patients. The majority (approximately 80%) of invasive Aspergillus infections is caused by Aspergillus fumigatus. The second most frequent (approximately 15-20%) pathogenic species is Aspergillus flavus and to a lesser extent, Aspergillus niger and Aspergillus terreus. Aspergillus flavus has emerged as a predominant pathogen in patients with fungal sinusitis and fungal keratitis in several institutions worldwide. To date, there has not been any publication exclusively reviewing the topic of A. flavus in the literature. This article reviews the microbiology, toxigenicity and epidemiology of A. flavus as well as describes the clinical characteristics, diagnosis and management of infections caused by this organism.

Minimizing the risk of recurrent or progressive invasive mold infections during stem cell transplantation or further intensive chemotherapy

The risk of recurrence or progression of prior invasive fungal infection, predominantly due to molds, is 11-33% during subsequent stem cell transplantations or myelosuppressive chemotherapy, with a high mortality. Risk factors at the time of transplant include active infection and having received <6 weeks of antifungal therapy, while after transplant prolonged neutropenia and graft-versus-host disease requiring aggressive immunosuppression are important. The use of peripheral blood stem cells has been associated with a lower risk. Minimal data are available regarding the role of preventative strategies such as surgical resection of pulmonary lesions and prophylactic granulocyte transfusions during neutropenia, the optimal duration of antifungal prophylaxis, and the appropriate monitoring strategy. This article critically evaluates these issues and provides recommendations for the secondary prophylaxis of invasive mold infections.

Clinical Issues Regarding Relapsing Aspergillosis and the Efficacy of Secondary Antifungal Prophylaxis in Patients with Hematological Malignancies

Advancements in early diagnosis and the introduction of effective agents have improved the rates of response of aspergillosis to primary antifungal therapy. These changes allow the subsequent continuation of cytotoxic chemotherapy and/or performance of hematopoietic stem cell transplantation in an increasing number of patients with hematological malignancies. These developments have increased interest in secondary prophylaxis of aspergillosis, because the resumption of myelotoxic chemotherapy in these patients is associated with high rates of relapse of this opportunistic mycosis in the absence of prophylaxis. However, the risk factors for relapsing invasive aspergillosis and the strategies for reducing risk are not well defined. Furthermore, differentiating aspergillosis relapse from reinfection with a new Aspergillus isolate is problematic when using the available laboratory tools. We summarize the existing knowledge regarding the pathogenesis of, risk factors for, and natural history of relapsing invasive aspergillosis and review the limited data regarding the role of secondary antifungal prophylaxis.

Fungal infections in nontransplant patients with hematologic malignancies

Fungal infections are a major cause of morbidity and mortality in patients with hematologic malignancies. Candida and Aspergillus species are the most important opportunistic fungal pathogens in this patient population. Dimorphic fungi can cause serious infection in immunocompetent persons, but infection is more likely to be disseminated in patients with compromised cell-mediated immunity. Cryptococcus neoformans and Pneumosystis carinii typically cause infections in persons with severe T-cell suppression. The frequency of rare pathogenic fungi commonly resistant to amphotericin B has significantly increased over the past 20 years among patients with hematologic malignancies. Examples of such emerging pathogens include Trichosporon, Fusarium, and Scedosporium species, and dark-walled molds. This article reviews the epidemiology, clinical manifestations, diagnostic evaluation, and treatment of the major fungal pathogens in nontransplant patients with hematologic malignancies.

Critical care of patients with cancer. Surgical considerations

Surgical evaluation of and therapy for the critically ill cancer patient continue to present significant challenges despite, or perhaps in part because of, an ongoing technologic refinement of therapeutic modalities within a modern ICU.

Clinical significance of Aspergillus fungaemia in patients with haematological malignancies and invasive aspergillosis

The clinical significance of Aspergillus fungaemia in the setting of a deep-seated aspergillosis has not been clearly established. Among 107 microbiologically documented Aspergillus infections in patients with haematological diseases observed over a 17-year period, blood cultures grew Aspergillus species from 10 cases. Aspergillus fungaemia was documented in 9 out of 89 (10.1%) patients with pulmonary aspergillosis at a median of 5 d from the onset of clinical signs of infection, and in one patient with central venous catheter focal infection. Five (50%) patients died as a result of fungal infection a median of 12 d (range 4--48) from the documentation of Aspergillus fungaemia. A comparison between cases of invasive aspergillosis with or without fungaemia showed that fungaemic patients were similar to those without positive blood cultures regarding clinical presentation, risk factors, clinical course and outcome. The diagnostic role of Aspergillus fungaemia in the setting of a deep-seated infection is limited because blood cultures become positive when a microbiological or clinical diagnosis of aspergillosis has already been performed. Aspergillus fungaemia does not necessarily seem to be correlated with a disseminated infection or a poorer prognosis.

Skin involvement as the first manifestation of systemic aspergillosis in patients after allogeneic hematopoietic cell transplantation

Skin involvement due to a systemic infection with Aspergillus species in the course of allogeneic hematopoietic cell transplantation is extremely rare. We report the clinical course of two patients with hematologic malignancies who underwent allogeneic hematopoietic cell transplantation (HCT) and developed disseminated skin involvement as the first clinical symptom of a proven systemic Aspergillus infection.

Diagnosis and management of rhinosinusitis before scheduled immunosuppression: a schematic approach to the prevention of acute fungal rhinosinusitis

Acute (invasive) fungal rhinosinusitis is an aggressive and potentially lethal complication of insulin dependent diabetes, as well as immunosuppression from chemotherapy and bone marrow transplant. The goal of this article is to describe methods to help with the diagnosis and treatment of sinusitis prior to developing this state of immune-compromise. This will help eliminate a significant risk factor for these patients that can lead to serious morbidity and ultimately mortality.

Prevention and prophylaxis of invasive fungal sinusitis in the immunocompromised patient

Fungal infections are a leading cause of morbidity and mortality among immunocompromised patients. Invasive fungal sinusitis is a devastating complication of immunosuppression. Treatment options are limited and often ineffective, making prevention important. Measures to decrease environmental exposure, indications for antifungal prophylaxis, and limitations of current regimens are discussed.

Value of Ga-67 SPECT in monitoring the effects of therapy in invasive aspergillosis of the sphenoid sinus

PURPOSE

We report a case of invasive sphenoid sinus aspergillosis clinically presenting as a pituitary mass.

METHODS

After exploration via the trans-sphenoidal approach and subsequent treatment with amphotericin-B, Ga-67 brain SPECT was performed twice to monitor the therapeutic effect.

RESULTS

Three months after antifungal treatment, Ga-67 brain SPECT showed partial resolution of the lesion in the sella turcica region. The patient continued with fluconazole treatment for another 2 months and received another Ga-67 brain SPECT, which showed complete clearing of the previous lesion.

CONCLUSION

Ga-67 brain SPECT may play a potentially useful role in monitoring the therapeutic effect of treatment of invasive sphenoid sinus aspergillosis.

Aspergillus fumigatus and aspergillosis

Aspergillus fumigatus is one of the most ubiquitous of the airborne saprophytic fungi. Humans and animals constantly inhale numerous conidia of this fungus. The conidia are normally eliminated in the immunocompetent host by innate immune mechanisms, and aspergilloma and allergic bronchopulmonary aspergillosis, uncommon clinical syndromes, are the only infections observed in such hosts. Thus, A. fumigatus was considered for years to be a weak pathogen. With increases in the number of immunosuppressed patients, however, there has been a dramatic increase in severe and usually fatal invasive aspergillosis, now the most common mold infection worldwide. In this review, the focus is on the biology of A. fumigatus and the diseases it causes. Included are discussions of (i) genomic and molecular characterization of the organism, (ii) clinical and laboratory methods available for the diagnosis of aspergillosis in immunocompetent and immunocompromised hosts, (iii) identification of host and fungal factors that play a role in the establishment of the fungus in vivo, and (iv) problems associated with antifungal therapy.

Antifungal susceptibility of Aspergillus species isolated from invasive oral infection in neutropenic patients with hematologic malignancies

OBJECTIVE

The aim of this study was to evaluate the relevance of in vitro antifungal susceptibility to clinical response in neutropenic patients with invasive oral aspergillosis.

STUDY DESIGN

Nine isolates of Aspergillus species were obtained from invasive oral infections in 9 patients with hematologic malignancies and tested for their in vitro susceptibility to amphotericin B, fluconazole, miconazole, 5-fluorocytosine, and itraconazole. Minimal inhibitory concentration values of the 5 drugs were obtained for each fungus through use of a microdilution broth method. The patients were treated with intravenous amphotericin B (30-50 mg/day) in combination with oral 5-fluorocytosine (3000-6000 mg/day) and/or oral itraconazole (200 mg/day).

RESULTS

Amphotericin B and itraconazole were found to be very active, with minimal inhibitory concentration values of 0.861 and 0.194 microg/mL, respectively. Miconazole and 5-fluorocytosine showed minimal inhibitory concentration values of 1.72 and 3.56 microg/mL, respectively. On the other hand, fluconazole FCZ showed low activity, with a minimal inhibitory concentration value in excess of 64.0 microg/mL. During neutropenia, combined antifungal chemotherapy stabilized oral aspergillosis and prevented the spread of oral lesions in 8 patients in whom neutrophil counts eventually recovered.

CONCLUSIONS

The results imply that in vitro susceptibility testing may serve as an informative parameter with respect to the efficacy of these antifungals in the treatment of invasive oral aspergillosis, inducing fungal stasis until the neutrophils recover.

A schematic approach to preexisting sinus disease for the immunocompromised individual

Fungal rhinosinusitis is an aggressive and potentially lethal complication of chemotherapy and bone marrow transplant-induced neutropenia. Preexisting noninvasive sinusitis may be a significant risk factor in this population. An illustrative case is presented where preexisting noninvasive fungal sinusitis developed into the tissue-invasive and angio-invasive form of aspergillosis during chemotherapy. We propose an algorithmic approach to all patients before chemotherapy or bone marrow transplantation. If there is a suspicion of sinusitis based on a screening questionnaire, we recommend an otolaryngology consultation and a CT of the paranasal sinuses. Evidence of sinus disease should then be treated aggressively before chemotherapy or a bone marrow transplantation. Close posttreatment surveillance during the neutropenic phase is necessary with "urgent" biopsies if recurrence of disease is suspected.

Clinical presentation of invasive aspergillosis

Invasive aspergillosis has increasingly been recognised to cause significant morbidity and mortality in immunocompromised patients. Fever unresponsive to broad-spectrum antibiotics is the earliest and most common sign of an invasive fungal infection. As invasive Aspergillus infections are usually acquired by inhalation of Aspergillus conidia, symptoms of a pulmonary infection such as cough, rales and marked pleuritic chest pain can be noted early in the course, whereas hemoptysis typically comes late after neutrophil recovery. Aspergillus infections of the upper respiratory tract may also involve the nasal cavity or sinuses resulting in nasal obstruction, epistaxis, facial pain, periorbital swelling and even palate destruction. Primary cutaneous infections present as non-purulent ulcerations and may be seen in association with implantable intravenous devices. Other sites of infections, such as the central nervous system, originate from dissemination of molds and may be suspected when focal neurological findings or meningism develop. The recognition of symptoms associated with invasive aspergillosis in patients at risk should prompt further diagnostic procedures, as an early diagnosis and immediate institution of antifungal therapy might improve the treatment outcome in this life-threatening condition.

Invasive Aspergillus sinusitis during bone marrow transplantation

Aspergillus sinusitis is usually a lethal condition in bone marrow transplanted patients. We report the case of a patient known to have a sinus infection with Aspergillus flavus before treatment with allogenic bone marrow transplantation for a refractory acute myelogenous leukemia. Exacerbation of the sinusitis during the neutropenic period required a multidisciplinary approach. Cure was achieved after treatment with a combination of surgery (Caldwell-Luc procedure), long term ABCD (amphotericin B colloidal dispersion) therapy (7 months) and granulocyte transfusions during the period preceding engraftment. The use of granulocyte transfusion in this salvage setting is discussed. Aggressive multimodality management of aspergillus sinusitis in immunosuppressed patients may lead to a cure and might not preclude allogenic transplantation.

Aspergillosis of the sphenoid sinus: presentation as a pituitary mass and postoperative gallium-67 imaging

Invasive aspergillosis of the paranasal sinuses is an uncommon, but well-recognized, form of fungal infection. We describe an elderly female patient with invasive aspergillosis of the sphenoid sinus and associated osteomyelitis of the skull base, with clinical presentation as a pituitary mass. Postoperative gallium scan showed intense uptake in the sphenoid sinus, which resolved after treatment with amphotericin-B. This case demonstrates some of the pathologic and clinical features of invasive aspergillosis and suggests a potential role for gallium-67 imagining in monitoring clinical response to therapy.

Pathological features of invasive oral aspergillosis in patients with hematologic malignancies

PURPOSE

Little is known about the characteristic macroscopic and microscopic changes that take place during the progression of oral invasive aspergillosis in immunocompromised patients. The aim of this study was to determine the relationship between the oral and histopathologic findings in these patients. Such a study would aid in understanding the early development of subsequent progression of the disease.

PATIENTS AND METHODS

Twelve patients with hematologic malignancies who developed invasive oral aspergillosis were studied. The condition was divided into three stages according to the oral findings at the time biopsy procedures were performed. Tissue sections from biopsy specimens were stained with hematoxylin and eosin for histopathologic study and the findings were evaluated in relation to the oral findings. Fungal cultures of biopsy specimens were also performed to confirm the causative organisms.

RESULTS

The diagnosis of oral aspergillosis was established in terms of both histologic and microbiologic evidence in all 12 patients. In the early stage (three patients), isolated areas of violaceous marginal gingiva consisted of degenerated epithelium and connective tissue infiltrated by fungal hyphae. In the advanced stage (four patients), the violaceous marginal gingiva had become transformed into gray necrotic lesions that extended to the attached gingiva. The necrotic lesions showed ulceration and were covered by a pseudomembrane containing fungal hyphae. At the base of the ulcers, connective tissue was occupied by proliferating fungal hyphae, with vascular invasion being observed. In the late stage (five patients), the ulcerated lesions had progressed, showing destruction of the alveolar bone and surrounding facial muscles, with infiltration of fungal hyphae unto the tissues. No inflammatory cellular reaction was observed until the hematologic status of the patients improved.

CONCLUSION

These findings indicate that invasive oral aspergillosis has three distinctive clinicopathological stages. Recognition of the different stages of invasive Aspergillus infections is helpful for correct diagnosis of the disease.

Oral complications associated with aspergillosis in patients with a hematologic malignancy. Presentation and treatment

Opportunistic mycotic infections, such as aspergillosis, can produce morbid consequences with or without aggressive therapy in an immunocompromised patient. Treatment including amphotericin B and resection of the infected tissue must be considered early in the overall management of the patient. We describe two patients with acute myelogenous leukemia who underwent intense cytoreductive therapy with bone marrow transplantation and an associated fungal infection treated with an investigational form of amphotericin B.

[Pulmonary invasive aspergillosis: value of treatment with intravenous amphotericin B administered in a triglyceride emulsion for parenteral usage]

Pulmonary invasive aspergillosis is a frequent and poor prognosis complication of immuno-deficiency and prolonged neutropenia. Its treatment is usually based on amphotericin B (0.7 to 1 mg/kg/d) given as intravenous infusions for at least 2 months. This therapy is limited by the side-effects of the drug including renal failure, myelosuppression, chills and fever. We present here the case of women with pulmonary invasive aspergillosis treated with a different modality of administration. The amphotericin B was given as a continuous infection at 2 mg/kg/d diluted in Intralipid, a triglyceridic mixture used in parenteral nutrition. Given by this way amphotericin B seems to have a good therapeutic efficiency and a mild toxicity limited to transient reduction in creatinine clearance with increased kaliuria. Other current approaches of invasive aspergillosis include the amphotericin B in liposomes, combination of amphotericin B with 5-fluorouracil and the triazolated compounds.

An algorithmic approach to aspergillus sinusitis

The effective management of paranasal sinus aspergillosis requires early diagnosis, histological classification, surgery and where appropriate, chemotherapy. Fungal sinusitis may be easily missed unless a high index of suspicion is maintained and specific culture and histology requested. The disease is classified into invasive and noninvasive types, each being divided into two subgroups: invasive aspergillosis may be either fulminant or indolent and noninvasive disease localized or allergic. The literature is reviewed and an algorithmic approach to aspergillus sinusitis proposed. The importance of histologically differentiating invasive from noninvasive aspergillosis prior to selecting the appropriate treatment options is stressed. CT scan should precede definitive surgery, and be used in follow-up. Close and prolonged follow-up is essential.

Use of amphotericin B aerosols for the prevention of pulmonary aspergillosis

Invasive pulmonary Aspergillus infections are increasingly recognized among severely neutropenic and/or immunosuppressed individuals. As the infections are usually acquired through the inhalation of Aspergillus conidia, at present prevention of invasive pulmonary aspergillosis consists mainly of the reduction of environmental exposure to aspergillus conidia. More recently, prophylaxis with amphotericin B aerosols has been investigated. Inhalations with amphotericin B aerosols significantly delayed mortality in an animal model of invasive pulmonary aspergillosis and high pulmonary concentrations of amphotericin B could be achieved. In man, pulmonary deposition of amphotericin B could also be demonstrated using commercially available nebulizers. Inhalations were well tolerated with little systemic absorption of the drug. In order to evaluate the efficacy of aerosol amphotericin B administrations for the prevention of invasive pulmonary aspergillosis, a prospective randomized trial has been initiated.

Prognostic factors of invasive pulmonary aspergillosis in leukemic patients

The study objective was to identify prognostic factors associated with survival in patients treated for acute leukemias who developed invasive aspergillosis (IA) during induction therapy. This retrospective analysis involved 21 patients treated in two hematologic centers over a six-year period. All were treated in protective isolated rooms with high-dose amphotericin B as soon as fungal infection was suspected. Ten (45%) of the twenty-one patients died. There was no statistical difference between the patients who survived and those who died in relation to the mean time of onset of IA or the total and mean daily dose of amphotericin B. On the other hand a favourable outcome correlated strongly with complete leukemic remission (p < 0.0001): all but one of the patients with objective residual leukemia died of IA, whereas all those who achieved complete hematological remission survived. In conclusion, it seems that the main vital prognostic factor in these leukemic patients with IA was the achievement of complete remission. We were unable to control IA in 10 of 11 patients with refractory leukemia, regardless of neutropenic status, despite early administration of high-dose amphotericin B. All the patients who achieved complete remission were successfully treated with amphotericin B.

[Invasive aspergillosis of the sphenoid sinus and paralysis of the 6th nerve]

A case of aspergillosis of the sphenoid sinus manifested as an isolated sixth nerve palsy occurred in a 74-year old diabetic woman who had no complaints of headache or symptoms suggestive of sinusitis. A CT scan demonstrated a large mass occupying the sphenoid and ethmoid sinuses extending posteriorly to the clivus. There was a calcific density within the opacified sinus and bony erosion of the sphenoid walls and the sella turcica. The patient underwent a sublabial transseptal sphenoidotomy with removal of necrotic material and debridement of the surrounding tissue. Histologic examination revealed granulation tissue with chronic inflammatory cells and abundant dichotomously branching hyphae. Postoperatively the patient was given amphotericin B and 5-fluorocytosine. Three months later the sixth nerve palsy had completely cleared and the patient had no other complaint. Sphenoid sinus aspergillosis is a rare disease and may have variable clinical manifestations according to involvement of different structures located closely to the sinus. Our patient developed an isolated sixth nerve palsy which was at onset considered to be caused by diabetes. Computerized tomography scans disclosed abnormalities strongly indicative of invasive aspergillosis. It illustrates the need of appropriate work-up in cases of an isolated sixth nerve palsy even in patients with diabetes or other risk factors.

Functional endoscopic sinus surgery in the immunocompromised child

Fungal sinusitis in the immunocompromised child is an aggressive, invasive process that may result in a fatal outcome if not diagnosed early. As a result of increasing use of bone marrow transplantation and new cytotoxic chemotherapeutic agents resulting in severe agranulocytopenia, more patients have become susceptible to fungal sinus disease. Functional endoscopic sinus surgery has emerged recently as an important surgical modality in the treatment of sinus disease in adults and children. Use of this technique in immunosuppressed children has allowed early diagnosis of fungal sinonasal disease, resulting in earlier surgical intervention. The high-quality fiberoptic capability of nasal endoscopes allows very detailed visualization of the internal anatomy of the nose and detects early mucosal changes as a result of intranasal fungal disease. Our experience using functional endoscopic sinus surgery in immunocompromised children over an 18-month period is reviewed. Our philosophy for diagnosis and management of immunocompromised children with suspected fungal sinonasal disease is discussed.

The infectious and hematologic otolaryngic complications of myelosuppressive cancer chemotherapy

The otolaryngologist-head and neck surgeon is frequently consulted to evaluate patients before the administration of myelosuppressive cancer chemotherapy. Fifty consecutive patients treated at the University of Pennsylvania Oncology Center were studied before and during chemotherapy for adult leukemia or bone marrow transplantation. Otolaryngic history, physical examination, radiographic studies, and hematologic surveys were analyzed for the duration of therapy in an attempt to identify risk factors for infectious and hematologic otolaryngic complications. Two-thirds of the patient studied experienced untoward effects that required the further attention of an otolaryngologist-head and neck surgeon. The various complications and associated correlations with the study parameters before and during chemotherapy are discussed.

Fungal sinusitis in immunocompromised children with neoplasms

This paper reviews the treatment and diagnosis of immunocompromised patients with fungal sinusitis at St Jude Children's Research Hospital. Sinusitis of all types was found to be more common in patients with hematopoietic neoplasms than in patients with solid tumors; 42% of patients with leukemia had abnormal sinus radiographs. Eight cases of pathologically proven fungal sinusitis were identified. All patients were undergoing chemotherapy for either acute myeloblastic leukemia or acute lymphoblastic leukemia and had neutrophil counts less than 100 cells/mm3. The most common findings were fever, facial pain, and abnormal sinus radiographs. Surveillance cultures of the upper aerodigestive system did not reliably predict sinus pathogens. An aggressive treatment approach consisting of early administration of amphotericin B (intravenously and via catheter irrigations of the sinuses) and surgical drainage is advocated. There was an 80% survival rate in patients in remission who were undergoing maintenance chemotherapy. All patients undergoing chemotherapy for relapse died.

Experimental basis for the clinical epidemiology of fungal infections. A review

Based on the concept that the agents of deep fungal infections can be divided into primary pathogens and opportunists the experimental basis for the clinical epidemiology of mycoses is outlined. Kinetics of experimental infections with opportunists and primary pathogens discriminate between the two fungal categories. Natural resistance eliminates opportunists and prevents the establishment of progressive infection in the normal host. Primary pathogens call upon mechanisms of adoptive cell mediated immunity for their control. Therefore athymic mice which are not more susceptible to opportunists than control mice, cannot control infection with primary pathogens. In order to induce comparable overwhelming opportunistic mycoses with reasonable challenge doses, non-specific phagocytic resistance has to be eliminated. In agreement with in vivo studies, in vitro studies of the susceptibility of fungi to killing by phagocytes point out, that the susceptibility of the tissue phase of fungi to killing by "immunologically unarmed" phagocytes discriminates between opportunists and primary pathogens. In order to restrain primary pathogenic fungi, phagocytes have also in vitro to call upon adoptive, T cell-dependent immune mechanisms, which appear superfluous for control of opportunists. This difference explains the discrepant opportunistic proclivities of the two fungal categories. Patients with defective phagocytic defenses are prone to opportunistic mycoses, while deficient cell mediated immunity results in a greater vulnerability to primary pathogens.

Aspergillosis of the sphenoid sinus simulating a pituitary tumor

Sphenoidal aspergillosis is an unusual cause of sella turcica enlargement. Pituitary abscess secondary to Aspergillus had been reported. In the present case, a woman with sphenoid sinus aspergillosis mimicked a pituitary tumor. This patient survived her infection with intact pituitary function following a transsphenoidal approach. No postoperative amphotericine-B and 5-fluorocytosine were necessary. CT scan revealed a mass occupying the sphenoid sinus extending to the sella turcica. Factors that should alert the clinican to the presence of a sphenoidal and pituitary abscess in a patient with sella turcica enlargement are prior episodes of sinusitis, meningitis and immunosuppression and, as in the present case, hyperglycemia.

Fungal infections in the immunocompromised host

With the increased number of immunocompromised patients there has been a concomitant increase in patient morbidity and mortality due to fungi. The etiologic microorganisms vary depending upon the type of immune dysfunction. Patients with malignancies and chemotherapy-induced neutropenia commonly are infected with Candida and Aspergillus. Other ubiquitous fungi such as Rhizopus, Fusarium, and Trichosporon are more frequently implicated as agents of disease in these patients. Patients with cell-mediated immune dysfunction such as acquired immune deficiency syndrome (AIDS) are susceptible to mucocutaneous candidiasis and pulmonary and disseminated cryptococcosis. Histoplasmosis and coccidioidomycosis have been particularly lethal infections in AIDS patients. Contributing factors such as broad-spectrum antibiotic use, intravenous catheterization, malnutrition, hyperalimentation, multiple surgical procedures and/or trauma, and steroids used either singly or in combination may also predispose patients to invasive fungal disease. Definitive diagnosis is often difficult to establish and usually requires invasive biopsy. Delay of culture results due to the time required to process specimens and to allow the fungus to grow also contributes to the poor results of therapy. Biopsy of skin lesions represents a useful technique for making a diagnosis. Recent advances in antifungal therapeutics promise to change the current approach to treatment for several of the mycoses. The availability of new oral azoles with spectra of activity that include aspergillosis and cryptococcosis, which currently require treatment with parenteral amphotericin B, may prove practical for prolonged oral therapy of otherwise lethal mycoses.

Nosocomial aspergillosis: environmental microbiology, hospital epidemiology, diagnosis and treatment

The purpose of this review is to characterize the environmental microbiology, hospital epidemiology, diagnosis and treatment of nosocomial aspergillosis. Appropriate environmental control measures are important in preventing or arresting an outbreak of nosocomial aspergillosis. These include selective environmental microbiological surveillance and floor to ceiling barriers during construction or renovation. These is particularly important for the bone marrow transplant units and units with persistently granulocytopenic patients. We have summarized the point source and cited or formulated the environmental correction measures relating to 25 outbreaks of nosocomial aspergillosis involving a total of more than 100 patients. The most frequent settings of nosocomial invasive aspergillosis occurred in granulocytopenic patients following respiratory infection from an airborne source, associated with hospital construction or contaminated ventilation systems.

Aspergillosis

Aspergillus spores are ubiquitous in the environment and may become concentrated in hospital ventilation systems. Colonization in normal hosts can lead to allergic diseases ranging from asthma to allergic bronchopulmonary aspergillosis. Normal hosts rarely develop invasive disease, which is primarily an infection of severely immunocompromised patients. The major predisposing factors for infection include prolonged neutropenia, chronic administration of adrenal corticosteroids, the insertion of prosthetic devices, and tissue damage due to prior infection or trauma. Since Aspergillus spp. are respiratory pathogens, the most common form of infection is pneumonia followed by sinusitis. Patients with preexistant cavitary disease may develop noninvasive aspergillomas. Most infections are caused by Aspergillus fumigatus. The organism is capable of invading across all natural barriers, including cartilage and bone. It has a propensity for invading blood vessels causing thrombosis and infarction. The diagnosis of pulmonary infection is usually difficult to establish because the organism is seldom cultured from sputum and can represent contamination in some cases. Therapy is immunocompromised hosts is less than satisfactory and amphotericin B is the only agent with significant activity. There is anecdotal evidence to suggest that the addition of 5-fluorocytosine to amphotericin B may be beneficial.

Aspergillus sinusitis in neutropenic patients with cancer: a review

Aspergillosis typically occurs in patients with reduced host defenses; such patients include renal and marrow recipients as well as patients with chemotherapy-induced myelosuppression. Pulmonary structures are most frequently involved; non-pulmonary involvement (including sinus) has not been frequently reported. In the present study, paranasal sinusitis occurred in 52 myelosuppressed cancer patients treated over 5 years at the UMCC with chemotherapy. Twenty-one patients had Aspergillus sinusitis; Aspergillus spp., including flavus and niger, were directly recovered from sinus in 19 of the 21 infections. Two other patients were considered clinically, although not microbiologically, documented. Multiple predisposing factors for Aspergillus sinusitis during the 60 days prior to infection diagnosis appear to exist; these include: 1) granulocyte count less than 500 mm3 (mean duration, 42 days versus 14 days for sinusitis of other etiology; P less than 0.001); 2) prolonged hospitalization (mean duration, 22 days versus 14 days for patients with non-fungal sinusitis; P less than 0.001); and 3) prolonged antibiotic therapy (mean duration, 22 days versus 9 days; P less than 0.001). The Aspergillus sinusitis resolved in 18 of 21 patients following treatment with amphotericin B; however, 11 of 18 patients had infection recurrence that always developed when tumor recurred and chemotherapy was reinstituted.

Aerosol amphotericin B is effective for prophylaxis and therapy in a rat model of pulmonary aspergillosis

Invasive pulmonary aspergillosis is a major life-threatening complication among transplant recipients and patients receiving cancer chemotherapy. In a rat model of progressive pulmonary aspergillosis that is characterized by hyphal bronchopneumonia, aerosol amphotericin B (aero-AmB; 1.6 mg/kg given 2 days before infection) significantly delayed mortality in rats compared with animals in a control group. The first death in the aero-AmB-treated group occurred on day 11, by which time seven of the eight control animals had died. The same dose of aero-AmB given as treatment (1.6 mg/kg given 24 h after infection and then daily for 6 days) was also effective. In this trial, eight of the ten animals treated with aero-AmB survived for 7 days, whereas only one of ten control animals survived. Colony counts in lung homogenates obtained 24 h after infection showed an 80-fold reduction in the number of viable spores in animals that had received 6.4-mg/kg doses of aero-AmB 2 days prior to infection. At 48 h after administering a single 1.6- or 3.2-mg/kg dose of aero-AmB, mean lung concentrations were 2.79 and 5.22 micrograms/g of tissue, respectively. We conclude, therefore, that aero-AmB kills inhaled spores and delays the progression of pulmonary aspergillosis by inhibiting mycelial proliferation.

Fungal infections of the immunocompromised host: clinical and laboratory aspects

Fungal infections of the immunocompromised host are being seen with greater frequency than ever before. In addition, a growing list of unusual and unexpected etiologic agents presents a unique and difficult challenge to the clinician and microbiologist. The clinical manifestations of opportunistic fungal infections are often not characteristic and, in many instances, may prevent a rapid diagnosis from being made. Clinical microbiology laboratories should consider any organism as a potential etiologic agent. This requires that all fungi recovered from immunocompromised patients be thoroughly identified and reported so that their clinical significance may be assessed. This review presents a brief discussion of the clinical and laboratory aspects of some fungal infections seen in this important group of patients.

Recurrent fungal pneumonias in patients with acute nonlymphocytic leukemia undergoing multiple courses of intensive chemotherapy

The records of 40 consecutive patients with newly diagnosed acute nonlymphocytic leukemia (ANLL) were reviewed to determine the risk of recurrent fungal pneumonia during multiple episodes of chemotherapy-induced granulocytopenia. Fungal pneumonias were diagnosed as proven or probable using defined pathologic, microbiologic, radiologic, and clinical criteria. Sixteen patients died without a complete remission; of these, all 11 who underwent autopsy were found to have invasive fungal pneumonia. The 24 patients who achieved a complete remission received one to nine (median, four) additional courses of intensive chemotherapy for remission consolidation and/or relapse, and experienced 132 episodes of severe granulocytopenia. Seven patients never had a pulmonary infection despite 34 granulocytopenic episodes. However, fungal pneumonia complicated 32 (33 percent) of 98 granulocytopenic episodes in the other 17 patients. Fifteen of the patients who achieved a complete remission had at least one episode of fungal pneumonia; 12 received further chemotherapy, and nine (75 percent) of these had a subsequent fungal pneumonia. In all, 17 (52 percent) of 33 subsequent granulocytopenic episodes experienced by patients with a prior fungal pneumonia were complicated by another fungal pneumonia. All four patients with a probable fungal pneumonia diagnosed antemortem who subsequently underwent autopsy were found to have invasive fungal disease. It would appear that patients with ANLL who have had one episode of fungal pneumonia are at high risk for recurrence during subsequent episodes of granulocytopenia. Empiric or even prophylactic amphotericin B therapy may be warranted for such patients.

Invasive aspergillosis in a patient with aplastic anemia receiving amphotericin B

Invasive mycotic infections are becoming more commonplace in immune-compromised hosts. Aspergillus species is the most commonly encountered fungal genus in our environment causing paranasal sinus fungal infection. Aspergillus paranasal sinus infections in the healthy host are readily treated and controlled. In the immune-compromised host this common organism can rapidly become fatal even if recognized and treated appropriately. We present a case history of a patient who died from her disease despite radical surgery and antifungicidal therapy. Recent methods for early diagnosis will be reviewed. Only one other case has been reported in the literature of a patient developing fulminant aspergillosis sinusitis while receiving amphotericin B.