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Ji J, Roland LT. Invasive fungal rhinosinusitis: current evidence and research opportunities. Curr Opin Otolaryngol Head Neck Surg 2024:00020840-990000000-00137. [PMID: 39146258 DOI: 10.1097/moo.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs. RECENT FINDINGS New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed. SUMMARY Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.
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Affiliation(s)
- Jenny Ji
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
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Sideris G, Arvaniti A, Giotakis E, Maragoudakis P, Delides A. Fourteen cases of acute invasive fungal rhinosinusitis: is there a place for less aggressive surgical treatment? Oral Maxillofac Surg 2024; 28:157-162. [PMID: 36201121 DOI: 10.1007/s10006-022-01120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Acute invasive fungal rhinosinusitis (AIFRS) is a rare, fulminant, angio-invasive infection with high mortality rate. Treatment of AIFRS includes aggressive surgical debridement combined with antifungal agents and treatment of the underlying disease. The aim of this study is to report our experience with this often fatal disease and estimate the long-term survival of AIFRS patients with more conservative surgery. METHODS A retrospective study was performed on immunocompromised adults with AIFRS from January 2011 to December 2020. The diagnosis was histologically confirmed by tissue fungus invasion. We analyze epidemiological and microbiological findings, the underlying disease and discuss our patients' treatment plan and long-term survival. RESULTS Fourteen patients were included in the study. Mean age was 53.8 ± 18.9 years. The underlying disease was hematologic malignancy in nine patients, diabetes mellitus in three, aplastic anemia in one, and renal/liver failure in one. Leukopenia was not significantly correlated with outcome or survival. Histological and culture findings revealed that Mucor/Rhizopus were the causative organisms in nine cases. All patients received systemic antifungal therapy. Surgery was performed in nine patients (endoscopic for all patients, combined in three with an external approach). Overall survival was 35.7% as five patients survived, two who underwent surgery, and three who were treated non-surgically. Nine patients died, two from AIFRS after central nervous system involvement and seven from their primary disease, free of fungi. Older individuals and patients with hematologic malignancies had a worse outcome. CONCLUSION Early surgical debridement, antifungal agents, and treatment of the underlying disease remain the cornerstones of AIFRS management. Prognosis is overall defined by the underlying disease and in some selected cases, medical treatment alone could be a reasonable option.
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Affiliation(s)
- Giorgos Sideris
- 2nd Otolaryngology Department, School of Medicine, National & Kapodistrian University of Athens, Attikon" University Hospital, Rimini 1, 124 62, Chaidari, Athens, Greece.
| | - Antonia Arvaniti
- 2nd Otolaryngology Department, School of Medicine, National & Kapodistrian University of Athens, Attikon" University Hospital, Rimini 1, 124 62, Chaidari, Athens, Greece
| | - Evaggelos Giotakis
- 1st Otolaryngology Department, School of Medicine, National & Kapodistrian University of Athens, "Ippokrateion" General Hospital, Athens, Greece
| | - Pavlos Maragoudakis
- 2nd Otolaryngology Department, School of Medicine, National & Kapodistrian University of Athens, Attikon" University Hospital, Rimini 1, 124 62, Chaidari, Athens, Greece
| | - Alexander Delides
- 2nd Otolaryngology Department, School of Medicine, National & Kapodistrian University of Athens, Attikon" University Hospital, Rimini 1, 124 62, Chaidari, Athens, Greece
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Lusida M, Arifijanto MV, Rachman BE, Alkaff FF. Difficulty in management of acute invasive fungal rhinosinusitis in Indonesia during the COVID-19 pandemic: A case report. Respir Med Case Rep 2023; 46:101916. [PMID: 38046461 PMCID: PMC10689262 DOI: 10.1016/j.rmcr.2023.101916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 12/05/2023] Open
Abstract
Invasive fungal rhinosinusitis is a rare disease with a high morbidity and mortality rate. Lately, COVID-19 has been associated with an increased incidence of this disease. We present the first case of COVID-19-associated acute invasive fungal rhinosinusitis found in Indonesia. The risk factors for the disease include corticosteroid use and antibiotic use. The case was complicated with left orbital cellulitis and cerebral abscess. Difficulty of management in Indonesia during the COVID-19 pandemic includes hesitancy of the patient to seek medical care and the availability of surgical team for COVID-19-positive patients. Monitoring of corticosteroid and antibiotic use must be emphasized during the pandemic. Awareness of the disease needs to be increased in Indonesia.
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Affiliation(s)
- Michael Lusida
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Surabaya, 60286, Indonesia
| | - M. Vitanata Arifijanto
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Surabaya, 60286, Indonesia
- Division of Tropical Medicine and Infectious Disease, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Surabaya, 60286, Indonesia
| | - Brian Eka Rachman
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Surabaya, 60286, Indonesia
- Division of Tropical Medicine and Infectious Disease, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Hospital, Surabaya, 60286, Indonesia
| | - Firas Farisi Alkaff
- Division of Pharmacology and Therapy, Department of Anatomy, Histology, And Pharmacology, Faculty of Medicine Universitas Airlangga, Surabaya, East Java 60132, Indonesia
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
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Roland LT, Humphreys IM, Le CH, Babik JM, Bailey CE, Ediriwickrema LS, Fung M, Lieberman JA, Magliocca KR, Nam HH, Teo NW, Thomas PC, Winegar BA, Birkenbeuel JL, David AP, Goshtasbi K, Johnson PG, Martin EC, Nguyen TV, Patel NN, Qureshi HA, Tay K, Vasudev M, Abuzeid WM, Hwang PH, Jafari A, Russell MS, Turner JH, Wise SK, Kuan EC. Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations. Int Forum Allergy Rhinol 2023; 13:1615-1714. [PMID: 36680469 DOI: 10.1002/alr.23132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.
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Affiliation(s)
- Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Christopher H Le
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Jennifer M Babik
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christopher E Bailey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Lilangi S Ediriwickrema
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California, Irvine, Irvine, California, USA
| | - Monica Fung
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joshua A Lieberman
- Department of Pathology and Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University Medical Center, Atlanta, Georgia, USA
| | - Hannah H Nam
- Division of Infectious Diseases, Department of Medicine, University of California, Irvine, Orange, California, USA
| | - Neville W Teo
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Penelope C Thomas
- Department of Radiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Blair A Winegar
- Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Abel P David
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Patricia G Johnson
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Elaine C Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Neil N Patel
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kaijun Tay
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Waleed M Abuzeid
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Aria Jafari
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew S Russell
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University Medical Center, Atlanta, Georgia, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
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John DS, Shyam K, Andrew D, Cicilet S, Deepalam SR. Utilizing CT soft-tissue markers as a screening tool for acute invasive fungal sinusitis. Br J Radiol 2022; 95:20210749. [PMID: 34919410 PMCID: PMC9153695 DOI: 10.1259/bjr.20210749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Acute invasive fungal sinusitis (AIFS) is a rapidly progressive disease, whose delayed identification results in poor outcomes, especially in immunocompromised individuals. A surge in of AIFS in the wake of the COVID-19 pandemic has lent additional morbidity and mortality to an already precarious clinical scenario. Early detection of AIFS in individuals who are symptomatic/ at risk can allow early therapy, enabling better patient outcomes. Our study aims to determine optimal soft-tissue markers on CT for the early detection of AIFS. METHODS In this case-control study, 142 patients with equal distribution of subjects were chosen based on histopathological diagnosis of AIFS; and their non-contrast CT scans were retrospectively assessed to determine the diagnostic utility of specific soft-tissue markers that would enable diagnosis of AIFS. RESULTS A total of nine markers with adequate sensitivity and specificity were identified, including pterygopalatine and sphenopalatine fossae, inferior orbital fissure and nasolacrimal duct involvement, premaxillary thickening, retro-antral and orbital stranding, and infratemporal muscle oedema. It was determined that the combined occurrence of any three out of nine markers was 91.5% sensitive and 95.9% specific for diagnosis of AIFS (p < 0.005). CONCLUSION Early, accurate detection of AIFS in predisposed individuals is possible with identification of soft-tissue markers on NECT, enabling early intervention. ADVANCES IN KNOWLEDGE Being the aggressive disease that it is, AIFS may be managed early if the index of suspicion is held high via CT imaging; which our diagnostic checklist aims at enabling.
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Affiliation(s)
- Deepa Susan John
- Department of Radiology, St. John’s Medical College Hospital, Bangalore, Karnataka, India
| | - Karthik Shyam
- Department of Radiology, St. John’s Medical College Hospital, Bangalore, Karnataka, India
| | - Dhilip Andrew
- Department of Radiology, St. John’s Medical College Hospital, Bangalore, Karnataka, India
| | - Soumya Cicilet
- Department of Radiology, St. John’s Medical College Hospital, Bangalore, Karnataka, India
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High Clinical Impact of Broad-Range Fungal PCR in Suspected Fungal Sinusitis. J Clin Microbiol 2021; 59:e0095521. [PMID: 34406798 DOI: 10.1128/jcm.00955-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Broad-range fungal PCR is a powerful tool for identifying pathogens directly from patient specimens; however, reported estimates of clinical utility vary and costs discourage universal testing. We investigated the diagnostic and clinical utility of broad-range fungal PCR by examining 9 years of results from sinonasal specimens, hypothesizing that this anatomic location would identify immunocompromised patients at high risk for invasive fungal disease. We retrospectively identified 644 PCRs and 1,446 fungal cultures from sinus sites. To determine the relative performance of each testing modality, we performed chart review on 52 patients having specimens submitted for culture and PCR on the same day. Positivity rates were significantly higher for PCR (37.1%) than culture (13.7%) but similar for formalin-fixed and fresh tissues (42.3% versus 34.6%). Relative to culture, PCR had significantly faster turnaround time to both preliminary (94.5 versus 108.8 h) and final positive (137.9 versus 278.5 h) results. Among chart-reviewed patients, 88% were immunocompromised, 65% had proven or probable fungal disease, and testing sensitivities for culture and PCR (67.5% and 85.0%) were not statistically different. Nevertheless, PCR identified pathogens not recovered by culture in 14.9% of cases and informed clinical decision-making in 16.7% of all reviewed cases, and sensitivity of PCR combined with culture (90.0%) was higher than that of culture alone. We conclude that broad-range fungal PCR is frequently informative for patients at risk of serious fungal disease and is complementary to and has faster turnaround time than culture. Formalin-fixed tissue does not adversely affect diagnostic yield, but anatomic site may impact assay positivity rates.
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Abstract
Mucormycosis is an aggressive, angioinvasive fungal infection with a predilection for the rhino-orbital cavity, predominantly in immunocompromised patients such as patients with uncontrolled diabetes. Prognosis is very poor, with a survival rate of 40% to 50%; therefore, early detection and initiation of treatment is paramount. Presenting symptoms are vague and mucormycosis is rare, so recognition, awareness, and knowledge of this infection are key to timely intervention and enhanced patient survival.
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Durand ML, Kitt TM, Song Y, Marty FM. Isavuconazole treatment of invasive fungal sinusitis: a post hoc analysis of the SECURE and VITAL trials. Clin Infect Dis 2021; 73:e1380-e1383. [PMID: 33914864 DOI: 10.1093/cid/ciab386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Indexed: 12/26/2022] Open
Abstract
This post-hoc analysis of international phase III isavuconazole trials identified 50 patients (90% immunocompromised or diabetic) with invasive fungal sinusitis (88% mucormycetes, Aspergillus) who received isavuconazole as primary (33) or salvage (17) therapy for median 82 days (range 2-882). Overall survival was 82% at day 42, 70% at day 84.
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Affiliation(s)
- Marlene L Durand
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | | | - Yi Song
- Astellas Pharma Global Development, Inc, Northbrook, IL
| | - Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA
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Seo MY, Seok H, Lee SH, Choi JE, Hong SD, Chung SK, Peck KR, Kim HY. Microinvasive Fungal Rhinosinusitis: Proposal of a New Subtype in the Classification. J Clin Med 2020; 9:jcm9020600. [PMID: 32102265 PMCID: PMC7074386 DOI: 10.3390/jcm9020600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Fungal rhinosinusitis (FRS) with mucosal invasion is not classified by the current criteria, and clinical reports on the topic are limited. The aim of this study was to present our 25-year experience on fungal balls with mucosal invasion that do not appear in the FRS classification. METHODS Of 1318 patients who underwent endoscopic surgery with paranasal FRS between November 1994 and July 2019, 372 underwent mucosal biopsies. Medical chart and pathology review were performed on 13 patients diagnosed as having fungal balls with mucosal invasion without accompanying tissue invasion. RESULTS Histopathologic findings identified all fungi as belonging to the Aspergillus species. In 13 patients, 7 fungal balls were located in the maxillary sinus, 3 in the sphenoid sinus, and 3 in both the maxillary and ethmoid sinuses. The median age at diagnosis was 67 years (interquartile range (IQR): 62-72), and the sex ratio was 1:2 (4 men and 9 women). Five patients had comorbidities-three with diabetes mellitus and two with hematologic malignancy-all of whom received postoperative antifungal therapy. The median duration of antifungal treatment was 13 weeks (IQR: 8-17). No recurrences occurred during the median follow-up period of 30 months (IQR: 22-43). CONCLUSIONS Patients who have been clinically diagnosed with a fungal ball and showed mucosal invasion but no vascular invasion, based on pathologic findings after surgery, may need a new FRS classification category, such as microinvasive FRS, and adjuvant antifungal treatment may be needed for immunocompromised patients with microinvasive FRS. KEY POINTS Fungal rhinosinusitis with mucosal invasion is different from fungal ball and invasive fungal rhinosinusitis and may be classified in a separate category as microinvasive FRS.
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Affiliation(s)
- Min Young Seo
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan 15355, Korea; (M.Y.S.); (S.H.L.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.E.C.); (S.D.H.); (S.-K.C.)
| | - Hyeri Seok
- Division of Infectious Diseases, Department of Medicine, Korea University College of Medicine, Korea University Ansan Hospital, Ansan 15355, Korea;
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea;
| | - Seung Hoon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan 15355, Korea; (M.Y.S.); (S.H.L.)
| | - Ji Eun Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.E.C.); (S.D.H.); (S.-K.C.)
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.E.C.); (S.D.H.); (S.-K.C.)
| | - Seung-Kyu Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.E.C.); (S.D.H.); (S.-K.C.)
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea;
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (J.E.C.); (S.D.H.); (S.-K.C.)
- Correspondence: ; Tel.: +82-2-3410-3579; Fax: +82-2-3410-3879
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Negri CE, Johnson A, McEntee L, Box H, Whalley S, Schwartz JA, Ramos-Martín V, Livermore J, Kolamunnage-Dona R, Colombo AL, Hope WW. Pharmacodynamics of the Novel Antifungal Agent F901318 for Acute Sinopulmonary Aspergillosis Caused by Aspergillus flavus. J Infect Dis 2019; 217:1118-1127. [PMID: 28968675 PMCID: PMC5909626 DOI: 10.1093/infdis/jix479] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/10/2017] [Indexed: 11/13/2022] Open
Abstract
Background Aspergillus flavus is one of the most common agents of invasive aspergillosis and is associated with high mortality. The orotomides are a new class of antifungal agents with a novel mechanism of action. An understanding of the pharmacodynamics (PD) of the lead compound F901318 is required to plan safe and effective regimens for clinical use. Methods The pharmacokinetics (PK) and PD of F901318 were evaluated by developing new in vitro and in vivo models of invasive fungal sinusitis. Galactomannan was used as a pharmacodynamic endpoint in all models. Mathematical PK-PD models were used to describe dose-exposure-response relationships. Results F901318 minimum inhibitory concentrations (MICs) ranged from 0.015 to 0.06 mg/L. F901318 induced a concentration-dependent decline in galactomannan. In the in vitro model, a minimum concentration:MIC of 10 resulted in suppression of galactomannan; however, values of approximately 10 and 9–19 when assessed by survival of mice or the decline in galactomannan, respectively, were equivalent or exceeded the effect induced by posaconazole. There was histological clearance of lung tissue that was consistent with the effects of F901318 on galactomannan. Conclusions F901318 is a potential new agent for the treatment of invasive infections caused by A flavus with PDs that are comparable with other first-line triazole agents.
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Affiliation(s)
- Clara E Negri
- Laboratório Especial de Micologia, Disciplina de Infectologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil.,Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
| | - Adam Johnson
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
| | - Laura McEntee
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
| | - Helen Box
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
| | - Sarah Whalley
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
| | | | - V Ramos-Martín
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
| | - Joanne Livermore
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
| | - Ruwanthi Kolamunnage-Dona
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Arnaldo L Colombo
- Laboratório Especial de Micologia, Disciplina de Infectologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
| | - William W Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, United Kingdom
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Silveira MLC, Anselmo-Lima WT, Faria FM, Queiroz DLC, Nogueira RL, Leite MGJ, Lessa RM, Simões BP, Tamashiro E, Valera FCP. Impact of early detection of acute invasive fungal rhinosinusitis in immunocompromised patients. BMC Infect Dis 2019; 19:310. [PMID: 30953465 PMCID: PMC6451285 DOI: 10.1186/s12879-019-3938-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 03/25/2019] [Indexed: 12/18/2022] Open
Abstract
Background Early diagnosis of acute invasive fungal rhinosinusitis (AIFRS) is vital to improving outcomes in immunocompromised patients. This study evaluated the impact of a systematic protocol with nasal endoscopy and biopsies to early detect AIFRS in immunocompromised patients. Additionally, we compared the accuracy of frozen-section biopsy and culture with formalin-fixed paraffin-embedded (FFPE) biopsy. Methods Retrospective cohort in a Tertiary Referral Hospital. Patients with the suspected diagnosis of AIFRS were evaluated following a standardized protocol, including serial nasal endoscopies and biopsies when necessary. The sensitivity and specificity of frozen-section biopsy and culture were also compared with FFPE. Results The mortality rate related to AIFRS of this standardized cohort (13/43) was 30.2%. Better outcomes were observed in patients with disease limited to the turbinates and in those with higher peripheral neutrophils count. Frozen-section biopsy positivity correlated with FFPE findings for fungi detection (p-value < 0.0001), with a sensitivity of 90.6%, specificity of 72.7%, and accuracy of 86.0%. Conclusion Implementation of this standardized protocol was related to a considerably low mortality rate among patients with suspected AIFRS at our Institution. Frozen-section biopsy revealed high accuracy to diagnose AIFRS. The current protocol including frozen-tissue biopsy improved the evaluation and survival rates of immunocompromised patients with presumed AIFRS.
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Affiliation(s)
- Mariana L C Silveira
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil
| | - Wilma T Anselmo-Lima
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil
| | - Francesca M Faria
- Division of Pathology, Clinics Hospital of Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Danielle L C Queiroz
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil
| | - Rodrigo L Nogueira
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil
| | - Marcelo G J Leite
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil
| | - Ricardo M Lessa
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil
| | - Belinda P Simões
- Department of Internal Medicine, Division of Hematology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Edwin Tamashiro
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil
| | - Fabiana C P Valera
- Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900 - 12° andar., São Paulo, São Paulo, CEP: 14049-900, Brazil.
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Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain. Head Neck Pathol 2018; 13:318-326. [PMID: 30209746 PMCID: PMC6684546 DOI: 10.1007/s12105-018-0965-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022]
Abstract
Acute invasive fungal rhinosinusitis (AIFRS) is a fulminant infection in immunocompromised patients requiring rapid diagnosis (DX), frequently made on frozen section (FS) of sinonasal biopsies, followed by prompt surgical debridement. However, FS interpretation is often difficult and DX sometimes not possible. In this study we sought to characterize reasons for misinterpretation and methods to improve diagnostic accuracy. The FS slides from 271 biopsies of suspected AIFRS in a 16-year period were reviewed and the morphologic features evaluated for their utility in DX. Recurring specific patterns of necrosis were identified, which to our knowledge have not been described in the literature. Although they provide strong evidence for AIFRS, identifying fungus consistently in necrotic tissue is essential for DX. Clues to identifying fungus and pitfalls in misidentification were identified, but even with expert knowledge of these, a gap in accurate DX remained. The key to FS DX of AIFRS is to improve fungus identification in necrotic tissues. Methods had been sought in the past to stain fungus at FS without consistent success. The Periodic Acid Schiff's Reaction for Fungi was modified by our histopathology department for use on frozen tissue (PASF-fs) resulting in effective staining of the fungus. It stained fungus on all 62 positive slides when applied retrospectively over hematoxylin and eosin (H&E) stained FSs and used prospectively at FS for DX. Although knowledge of histologic morphology on FS is important, the crucial value of this study is the novel use of PASF-fs to identify fungus in the DX of AIFRS.
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Wandell GM, Miller C, Rathor A, Wai TH, Guyer RA, Schmidt RA, Turner JH, Hwang PH, Davis GE, Humphreys IM. A multi-institutional review of outcomes in biopsy-proven acute invasive fungal sinusitis. Int Forum Allergy Rhinol 2018; 8:1459-1468. [DOI: 10.1002/alr.22172] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Grace M. Wandell
- Department of Otolaryngology; University of Washington; Seattle WA
| | - Craig Miller
- Department of Otolaryngology; University of Washington; Seattle WA
| | | | - Travis Hee Wai
- Department of Biostatistics; University of Washington; Seattle WA
| | - Richard A. Guyer
- Department of Otolaryngology; Vanderbilt University; Nashville TN
| | | | - Justin H. Turner
- Department of Otolaryngology; Vanderbilt University; Nashville TN
| | - Peter H. Hwang
- Department of Otolaryngology; Stanford University; Stanford CA
| | - Greg E. Davis
- Department of Otolaryngology; University of Washington; Seattle WA
| | - Ian M. Humphreys
- Department of Otolaryngology; University of Washington; Seattle WA
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14
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Gilde JE, Xiao CC, Epstein VA, Liang J. Deadly Sphenoid Fungus-Isolated Sphenoid Invasive Fungal Rhinosinusitis: A Case Report. Perm J 2018; 21:17-032. [PMID: 29236649 DOI: 10.7812/tpp/17-032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Acute invasive fungal rhinosinusitis (AIFRS) is a potentially fatal infection, usually affecting immunocompromised patients. Isolated sphenoid sinus involvement is rare and has been reported in only a few cases. We discuss the clinical characteristics, histopathologic features, and differential diagnosis of AIFRS of the sphenoid sinus. CASE PRESENTATION A 57-year-old man with a history of refractory non-Hodgkin lymphoma and neutropenia presented with a 1-week duration of left-sided headache and ipsilateral cheek paresthesia. Nasal endoscopy showed mucoid drainage from the sphenoethmoidal recess. Magnetic resonance imaging demonstrated left sphenoid mucosal thickening and enhancement along the adjacent skull base. The patient underwent endoscopic sinus surgery with extended sphenoidotomy and débridement. The lateral wall and recess of the left sphenoid sinus demonstrated pale mucosa and fungal debris. Pathologic analysis demonstrated necrotic tissue and fungal hyphae with angioinvasion. Microbiology studies isolated Aspergillus fumigatus. The right maxillary sinus contained a synchronous fungal ball, which was removed during surgery; there was no evidence of tissue necrosis or invasive fungus in the maxillary sinus. He was treated with long-term voriconazole therapy, and 6-month follow-up showed disease resolution. DISCUSSION AIFRS should be considered in the differential diagnosis of immunocompromised patients with nonspecific sinonasal symptoms. Usually, AIFRS is diffuse with multiple sinus involvement; however, isolated sphenoid AIFRS can occur. This is one of the few cases of AIFRS demonstrating isolated sphenoid involvement and is thought to be the first case showing a synchronous noninvasive fungal ball of another sinus cavity. Prompt recognition and surgical treatment may be curative and lifesaving.
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Affiliation(s)
- Jason E Gilde
- Otolaryngology and Head and Neck Surgery Resident at the Oakland Medical Center in CA.
| | - Christopher C Xiao
- Otolaryngology and Head and Neck Surgery Resident at the Oakland Medical Center in CA.
| | | | - Jonathan Liang
- Head and Neck Surgeon at the Oakland Medical Center in CA.
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15
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Melancon CC, Clinger JD. The Use of Frozen Section in the Early Diagnosis of Acute Invasive Fungal Sinusitis. Otolaryngol Head Neck Surg 2017; 157:314-319. [DOI: 10.1177/0194599817697279] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Acute invasive fungal sinusitis (AIFS) remains a significant cause of morbidity and mortality in the immunocompromised patient population. Early diagnosis is key to improving patient outcomes. Frozen section biopsies have been shown to decrease time to diagnosis when compared with permanent pathology. However, its accuracy has not been adequately described in the literature, specifically in regard to AIFS. The aim of this study is to evaluate the statistical diagnostic accuracy of frozen sections and to review the etiology, clinical presentation, and current diagnostic protocols in management of AIFS. Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods Retrospective review included 67 pathologic records in Co-Path, with search criteria including invasive fungal, clinical history, frozen section, and final diagnosis between the dates of 2006 and 2015. Results Sixty-seven cases were reviewed per the search criteria in Co-Path. Of these, 31 met further criteria of having had frozen section analysis. Variables such as sensitivity, specificity, positive predictive value, and negative predictive value were assessed. All 21 positive frozen sections correlated with positive permanent pathology, giving a positive predictive value of 100%. Frozen section biopsies were 87.5% sensitive and 100% specific. Conclusion Early diagnosis of AIFS has been shown to decrease morbidity and mortality. Frozen section biopsies remain key in obtaining an early diagnosis among patients with a high clinical suspicion for invasive fungal sinusitis. Frozen section biopsies positive for invasive fungal pathology were universally consistent with definitive diagnosis.
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Affiliation(s)
- C. Claire Melancon
- Department of Otolaryngology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - John D. Clinger
- Department of Otolaryngology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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16
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Papagiannopoulos P, Lin DM, Al-Khudari S, Rajan K, Reddy S, Gattuso P, Tajudeen B, Batra PS. Utility of intraoperative frozen sections in surgical decision making for acute invasive fungal rhinosinusitis. Int Forum Allergy Rhinol 2017; 7:502-507. [PMID: 28182334 DOI: 10.1002/alr.21918] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/30/2016] [Accepted: 11/27/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acute invasive fungal rhinosinusitis (AIFRS) represents a fulminant, potentially fatal, disease process in immunocompromised patients. The diagnosis often rests on high index of clinical suspicion, with relative paucity of data on the diagnostic and therapeutic implications of intraoperative frozen sections. METHODS Retrospective review was performed for 18 cases undergoing endoscopic sinus surgery for AIFRS. Reliability of intraoperative frozen section diagnosis was evaluated for all patients using final pathology as the gold standard. RESULTS A total of 66 frozen sections were performed. Diagnostic accuracy of frozen sections illustrated sensitivity of 72.7% (95% confidence interval [CI], 0.57 to 0.85), specificity of 100% (95% CI, 0.85 to 1.00), positive predictive value (PPV) of 100% (95% CI, 0.89 to 1.00), and negative predictive value (NPV) of 64.7% (95% CI, 0.46 to 0.80). There was no statistically significant difference in sensitivity of frozen sections in cases of Mucor and Aspergillus at 68.8%% and 76.2%, respectively (p = 0.61). CONCLUSION This study represents the largest series assessing the diagnostic accuracy of frozen section analysis in AIFRS. Frozen section analysis is an effective tool for guiding intraoperative decision making in patients with AIFRS with a high PPV. A Low NPV underscores the importance of clinical suspicion and intraoperative decision making based on endoscopic findings when negative frozen section results are encountered. Further, frozen section analysis appears to be equally effective in detecting either Mucor or Aspergillus.
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Affiliation(s)
- Peter Papagiannopoulos
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
| | - Diana Murro Lin
- Department of Pathology, Rush University Medical Center, Chicago, IL
| | - Samer Al-Khudari
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
| | - Kumar Rajan
- Department of Biostatistics, Rush University Medical Center, Chicago, IL
| | - Swathi Reddy
- Department of Pathology, Rush University Medical Center, Chicago, IL
| | - Paulo Gattuso
- Department of Pathology, Rush University Medical Center, Chicago, IL
| | - Bobby Tajudeen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
| | - Pete S Batra
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
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Clinical Manifestation and Diagnosis of Invasive Fungal Sinusitis in Patients with Hematological Malignancy. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2016. [DOI: 10.5812/archcid.36566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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