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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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Erami M, Aboutalebian S, Hashemi Hezaveh SJ, Matini AH, Momen-Heravi M, Ahsaniarani AH, Arani SS, Ganjizadeh M, Mirhendi H. Invasive Fusarium rhinosinusitis in COVID-19 patients: report of three cases with successful management. Front Cell Infect Microbiol 2023; 13:1247491. [PMID: 37780844 PMCID: PMC10538539 DOI: 10.3389/fcimb.2023.1247491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Invasive fungal rhinosinusitis (IFRS) is a life-threatening infection that can occur in immunocompromised patients, including those with COVID-19. Although Mucorales and Aspergillus species are the most common causes of IFRS, infections caused by other fungi such as Fusarium are rare. In this report, we present three cases of proven rhinosinusitis fusariosis that occurred during or after COVID-19 infection. The diagnosis was confirmed through microscopy, pathology, and culture, and species identification of the isolates was performed by DNA sequencing the entire ITS1-5.8 rRNA-ITS2 region and translation elongation factor 1-alpha (TEF-1α). Antifungal susceptibility testing was conducted according to CLSI guidelines. The causative agents were identified as Fusarium proliferatum, F. oxysporum + Aspergillus flavus, and F. solani/falciforme. Treatment involved the administration of antifungal medication and endoscopic sinus surgery to remove the affected mucosa, leading to the successful resolution of the infections. However, one patient experienced a recurrence of IFRS caused by A. flavus 15 months later. Early diagnosis and timely medical and surgical treatment are crucial in reducing mortality rates associated with invasive fusariosis. Additionally, the cautious use of corticosteroids in COVID-19 patients is highly recommended.
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Affiliation(s)
- Mahzad Erami
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Shima Aboutalebian
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Jamal Hashemi Hezaveh
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hassan Matini
- Department of Pathology and Histology, School of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Mansooreh Momen-Heravi
- Department of Infectious Disease, School of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Amir Hossein Ahsaniarani
- Department of Otorhinolaryngology, School of Medicine, Matini Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Shirin Shafaee Arani
- Department of Pathology and Histology, School of Medicine, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohsen Ganjizadeh
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Hossein Mirhendi
- Department of Medical Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Mycology Reference Laboratory, Research Core Facilities Laboratory, Isfahan University of Medical Sciences, Isfahan, Iran
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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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Villamor P, Arango V, Cortes C, de la Torre C. Pediatric invasive fungal rhinosinusitis. Front Pediatr 2023; 11:1090713. [PMID: 37181422 PMCID: PMC10167005 DOI: 10.3389/fped.2023.1090713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Pediatric invasive fungal rhinosinusitis (PIFR) is a rapidly progressive, potentially fatal disease. Previous medical literature demonstrates that its early diagnosis significantly reduces the risk of mortality in these patients. This study aims to present an updated clinical algorithm for optimized diagnosis and management of PIFR. A comprehensive review was conducted with only original, full-text articles published in English and Spanish from Cochrane Library, Pub-Med/MEDLINE, Embase, Scopus, and Google Scholar between January 2010 and June 2022. Relevant information was extracted and then integrated to develop a clinical algorithm for a proper diagnosis and management of PIFR.
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Affiliation(s)
- Perla Villamor
- Pediatric Otolaryngologist, Hospital Serena del Mar, Cartagena, Colombia
- Hospital Infantil Napoleón Franco Pareja, Cartagena, Colombia
| | - Valeria Arango
- Otolaryngology Resident, Faculty of Medicine, Universidad de Cartagena, Cartagena, Colombia
| | - Cristina Cortes
- Pediatric Otolaryngologist, Hospital Infantil de México Federico Gómez, México City, México
| | - Carlos de la Torre
- Pediatric Otolaryngologist, Hospital Infantil de México Federico Gómez, México City, México
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Breakthrough Acute Necrotizing Invasive Fungal Rhinosinusitis by Alternariaalternata in a Patient with Acute Lymphoblastic Leukemia on Anidulafungin Therapy and Case-Based Literature Review. J Fungi (Basel) 2022; 8:jof8080879. [PMID: 36012868 PMCID: PMC9410131 DOI: 10.3390/jof8080879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/05/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Alternaria spp. have emerged as opportunistic pathogens particularly in immunosuppressed patients. A case of a breakthrough acute invasive fungal rhinosinusitis (AIFRS), caused by Alternaria alternata, is reported in a patient with acute lymphoblastic leukemia (ALL) on anidulafungin therapy, who was successfully treated with liposomal amphotericin B and surgical intervention. To date, 20 cases of AIFRS due to Alternaria spp. have been described, 19 in the USA and 1 in Chile, making this case report the first case of AIFRS due to Alternaria in Europe. The patients had median (range) age 25 (2-56) years (65% female), almost all of them (19/20) with hematological diseases and severe neutropenia (8-41 days pre-infection). Amphotericin B was the most frequently used antifungal agent, either alone or in combination. In all of the cases, systemic antifungal therapy was combined with surgery. Despite stabilization or improvement of the AIFRS, mortality was 38% (5 days to 8 months post-surgical debridement) due to their underlying disease or other infections without sign of AIFRS at autopsy.
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Invasive Rhinosinusitis Caused by Alternaria infectoria in a Patient with Autosomal Recessive CARD9 Deficiency and a Review of the Literature. J Fungi (Basel) 2022; 8:jof8050446. [PMID: 35628702 PMCID: PMC9144991 DOI: 10.3390/jof8050446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022] Open
Abstract
Phaeohyphomycoses comprise a heterogeneous group of fungal infections caused by dematiaceous fungi and have primarily been reported in patients with underlying acquired immunodeficiencies, such as hematological malignancies or solid-organ transplants. Over the past decade, a growing number of patients with phaeohyphomycosis but otherwise healthy were reported with autosomal recessive (AR) CARD9 deficiency. We report a 28-year-old woman who presented with invasive rhinosinusitis caused by Alternaria infectoria. Following a candidate gene sequencing approach, we identified a biallelic loss-of-function mutation of CARD9, thereby further broadening the spectrum of invasive fungal diseases found in patients with inherited CARD9 deficiency. In addition, we reviewed 17 other cases of phaeohyphomycosis associated with AR CARD9 deficiency. Physicians should maintain a high degree of suspicion for inborn errors of immunity, namely CARD9 deficiency, when caring for previously healthy patients with phaeohyphomycosis, regardless of age at first presentation.
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Lee B, Yin D, August K, Noel-Macdonell J, Tracy M, Jensen D. Clinical predictors of invasive fungal rhinosinusitis in a tertiary pediatric hospital. Int J Pediatr Otorhinolaryngol 2022; 155:111065. [PMID: 35183919 DOI: 10.1016/j.ijporl.2022.111065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/18/2021] [Accepted: 02/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Invasive fungal rhinosinusitis (IFRS) is a potentially fatal disease that affects the severely immunocompromised and requires aggressive treatment. The objective of this study is to better describe predictors of biopsy positivity in patients at high risk of IFRS at a pediatric hospital. METHODS This was a single-center case-control study of 36 patients (37 total biopsies) ≤ 21 years old with one of five high-risk oncologic/hematologic diagnoses who underwent operative endoscopy for clinical suspicion for IFRS. IFRS positivity was defined histologically. Collected information included patient demographics, primary diagnosis, oncologic relapses, time from diagnosis to biopsy, clinical characteristics, and endoscopic findings. These data were used to create a simple predictive scoring system. RESULTS 17 patients had biopsy-proven IFRS (IFRS(+)) for an overall incidence of 2.1% in the designated high-risk population. Average time from most recent oncologic development (diagnosis, relapse, or hematopoietic stem-cell transplant) to biopsy in the IFRS(+) group was 2.09 months (SD = 2.26), and 7.28 months in the IFRS(-) group (SD = 9.17) (p = 0.009). Clinical characteristics did not differentiate between IFRS(+) and IFRS(-). Bedside endoscopy performed poorly, as it was interpreted as normal in 42.8% of IFRS(+) and 53.8% of IFRS(-). In contrast, the presence of any positive endoscopic finding intra-operatively was highly specific for IFRS(+) (94%) with moderate sensitivity (70%), and the difference in rate of positivity between groups was statistically significant (p < 0.001). CONCLUSION Operative endoscopy with biopsy remains the gold-standard to rule-out IFRS in the setting of high clinical suspicion. Time elapsed from most recent oncologic development to clinical concern for IFRS may influence the likelihood of disease, though this requires further study. Clinical symptoms and bedside endoscopy were not predictive and should be used with caution in decision-making.
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Affiliation(s)
- Brennan Lee
- School of Medicine, Univ. of Kansas, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Dwight Yin
- Pediatrics - Divisions of Infectious Diseases and Clinical Pharmacology, Children's Mercy Hosp., 2401 Gillham Rd., Kansas City, MO, 64108, USA; Department of Pediatrics, University of Missouri - Kansas City School of Medicine, 2411 Holmes St, Kansas City, MO, 64108, USA.
| | - Keith August
- Pediatrics - Division of Hematology/Oncology, Children's Mercy Hosp., 2401 Gillham Rd., Kansas City, MO, 64108, USA; Department of Pediatrics, University of Missouri - Kansas City School of Medicine, 2411 Holmes St, Kansas City, MO, 64108, USA.
| | - Janelle Noel-Macdonell
- Health Services and Outcomes Research, Children's Mercy Hosp., 2401 Gillham Rd., Kansas City, MO, 64108, USA; Department of Pediatrics, University of Missouri - Kansas City School of Medicine, 2411 Holmes St, Kansas City, MO, 64108, USA.
| | - Meghan Tracy
- Surgery - Division of Pediatric Otolaryngology, Children's Mercy Hospital, 2401 Gillham Rd., Kansas City, MO, 64108, USA.
| | - Daniel Jensen
- Surgery - Division of Pediatric Otolaryngology, Children's Mercy Hospital, 2401 Gillham Rd., Kansas City, MO, 64108, USA; Department of Pediatrics, University of Missouri - Kansas City School of Medicine, 2411 Holmes St, Kansas City, MO, 64108, USA.
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Ferdjallah A, Nelson KM, Meyer K, Jennissen CA, Ebens CL. Isavuconazonium Sulfate Use in Multi-Modal Management of Invasive Mucormycosis in Four Pediatric Allogeneic Hematopoietic Cell Transplant Patients. J Pediatr Pharmacol Ther 2021; 26:863-867. [PMID: 34790078 DOI: 10.5863/1551-6776-26.8.863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/04/2021] [Indexed: 11/11/2022]
Abstract
Prolonged neutropenia increases the risk for lethal invasive fungal infections (IFIs) such as those caused by Rhizopus species. Isavuconazonium sulfate is a new triazole that lacks pediatric dosing recommendations. Clinical courses of 4 pediatric patients with IFIs in the peri-allogeneic hematopoietic cell transplantation (alloHCT) period between 2015 and 2017 were reviewed. The reviews included previously unreported pharmacokinetic and safety data, and the IFIs included Rhizopus. Isavuconazonium sulfate was initiated with a loading dose followed by daily dosing, adjusted to a goal trough concentration of >3 mg/L based on adult literature. This target was achieved at a median of 7 days, demonstrating varying rates of metabolism. Renal insufficiency, electrolyte disturbances, and transaminitis were noted, although attribution was confounded by other alloHCT complications. One patient survived infection-free to hospital discharge and 1 of 3 deceased patients had evidence of an unresolved IFI (case 2). Case 2 was subtherapeutic for 39% of the duration of treatment, compared with others at an average of 29%, suggesting this target trough to be clinically relevant because case 2 demonstrated positive sinus and nasal cultures for Rhizopus on autopsy. We recommend initiation of isavuconazonium 10 mg/kg with a maximum dose of 372 mg. A loading dose of 10 mg/kg is used every 8 hours for 6 doses followed by 10 mg/kg dosing every 24 hours. Monitoring must continue beyond steady state. If early monitoring is not possible, we recommend a first drug level at week 3. If dose increases are required, a partial reload has been more successful instead of increasing daily doses. Further larger studies are needed to demonstrate optimum dosing in pediatric patients.
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Redmann AJ, Myer CM, Khandelwal P, Danzinger-Isakov L. Invasive fungal pharyngitis in a pediatric bone marrow transplant patient. Pediatr Transplant 2021; 25:e13853. [PMID: 33484226 DOI: 10.1111/petr.13853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 12/27/2022]
Abstract
Invasive fungal disease of the head and neck is a potentially fatal infection most commonly seen in immunocompromised patients. Even in the setting of combined surgical and medical treatment, prognosis is generally poor. We report the first pediatric case of invasive fungal pharyngitis and summarize a review of the literature. A 10-year-old female patientwith aplastic anemia status post-bone marrow transplant and accompanying immunosuppression initially presented with a diagnosis of a peritonsillar abscess. Incision and drainage did not show purulence, but culture grew out Rhizopus species. Immediately after diagnosis, the patient was treated successfully with aggressive staged surgical debridement and antifungal medications and had an excellent functional outcome 2 years after initial presentation. Invasive fungal disease is most common in the sinonasal region, but alternative sites of disease must be considered in immunocompromised patients who present with atypical symptoms.
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Affiliation(s)
- Andrew J Redmann
- ENT and Facial Plastic Surgery, Children's of Minnesota, Minneapolis, MN, USA.,Department of Otolaryngology, University of Minnesota, Minneapolis, MN, USA
| | - Charles M Myer
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Pooja Khandelwal
- Division of Bone Marrow Transplant and Immune Deficiency, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lara Danzinger-Isakov
- Division of Pediatric Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Rodrigues LCB, Guimaraes AF, de Oliveira IS, de Sousa PHM, de Castro Romanelli RM, Kakehasi FM, de Sá Rodrigues KE. Acute invasive fungal rhinosinusitis in pediatric patients with oncohematological diseases. Hematol Transfus Cell Ther 2020; 44:32-39. [PMID: 33288493 PMCID: PMC8885399 DOI: 10.1016/j.htct.2020.08.016] [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: 07/03/2020] [Revised: 08/06/2020] [Accepted: 08/21/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Invasive fungal diseases represent important causes of morbidity and mortality among pediatric oncohematological patients. Acute invasive fungal rhinosinusitis is a rare and aggressive disease that occurs mainly in immunocompromised patients. The mortality rate is high and therefore, accurate and early diagnosis is essential. Objectives The aim of this study was to describe the frequency of acute invasive fungal rhinosinusitis among pediatric oncohematological patients and characterize them with confirmed diagnoses. Methods This was a retrospective study that analyzed the medical records of pediatric patients diagnosed with oncohematological diseases and suspected fungal infections, who were included after obtaining informed consent, from January to December 2017, in the pediatric unit of a tertiary university hospital. Data collected from medical record analysis included the following: underlying diagnosis, absolute neutrophil count, clinical presentation, culture and biopsy results, surgical procedures performed, survival and mortality. Results A total of 27 patients were evaluated, with three suspected cases of acute invasive fungal rhinosinusitis. Histopathological and microbiological analyses confirmed two cases. In both cases, the pathogen isolated in the culture was Fusarium sp. The two confirmed cases were female, aged 12 and 14 years, both with an absolute neutrophil count of 10 cells/μL. The underlying disease of the first patient was acute myeloid leukemia (subtype M5), whereas the second patient presented idiopathic bone marrow aplasia. Conclusion Both confirmed cases of acute invasive fungal rhinosinusitis presented with constitutional symptoms and signs of nasal and sinusital inflammation. This demonstrates the importance of fever as a symptom in immunocompromised patients and it should prompt otorhinolaryngological investigation.
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Affiliation(s)
| | | | | | | | | | - Fabiana Maria Kakehasi
- Hospital das Clínicas da Universidade Federal Minas Gerais (HC UFMG), Belo Horizonte, MG, Brazil
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Orman G, Kralik SF, Desai N, Meoded A, Vallejo JG, Huisman TAGM, Tran BH. Imaging of Paranasal Sinus Infections in Children: A Review. J Neuroimaging 2020; 30:572-586. [PMID: 32472739 DOI: 10.1111/jon.12737] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
Paranasal sinuses (PNS) infections are common in children. They may cause common and well-known complications, but also, unusual and potentially devastating complications. Diagnosing PNS infections and complications in children requires knowledge of the unique anatomy of the nasal cavity and the PNS. In fetal life, nasal mucosa evaginations into the lateral nasal walls initiate the development of the PNS. The PNS continue to develop after birth and complete their maturation and pneumatization at different ages during childhood which makes the pattern of PNS infections determined by patient age. Complications are caused by direct spread of the infection to the orbit, face, intracranial or osseous structures or hematogenous spread of the infection to the intracranial structures. Emergent imaging studies are often necessary in the evaluation of the complications in pediatric patients when the symptoms persist for 10 days and/or if there is evidence of intracranial or orbital complications. In addition, immunocompromised children are especially vulnerable to developing unusual complications. Computed tomography (CT) is excellent for determining whether there is intraorbital extension of PNS disease. However, when the infection approaches the orbital apex, a magnetic resonance imaging (MRI) study with contrast is necessary to assess spread into the cavernous sinus and the intracranial compartment. The goal of this manuscript is to review and characterize imaging findings of PNS infections using CT and MRI allowing determination of the extent of PNS infections and their common and unusual complications in children. In addition, a summary of the development of the normal PNS is provided.
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Affiliation(s)
- Gunes Orman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Nilesh Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Avner Meoded
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Jesus G Vallejo
- Department of Pediatrics, Section of Infectious Diseases, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | | | - Brandon H Tran
- Edward B. Singleton Department of Radiology, Texas Children's Hospital, Houston, TX
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Factors associated with all-cause mortality in pediatric invasive fungal rhinosinusitis. Int J Pediatr Otorhinolaryngol 2020; 129:109734. [PMID: 31683190 DOI: 10.1016/j.ijporl.2019.109734] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/16/2019] [Accepted: 10/16/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pediatric invasive fungal rhinosinusitis (PIFR) is a potentially lethal infection seen in immunocompromised pediatric patients. Even with timely treatments, mortality ranges between 18 and 80% of the cases. OBJECTIVE To analyze the factors associated with all-cause mortality in pediatric patients with acute invasive fungal rhinosinusitis. SETTING Tertiary pediatric referral center. RESULTS A total of 18 patients were included, 12 male and 6 female. The average age at diagnosis was 8.7 years (range 4 months-17 years), with 56% overall mortality and 44% survival after 60 months. The most common cause of immunosuppression was acute lymphoblastic leukemia. The only factor found affecting mortality was a time between diagnosis and surgery greater than 7 days. CONCLUSION PIFR is an aggressive entity with high mortality. An appropriate diagnosis with an opportune surgical debridement followed by systemic antifungal therapy is essential to improve survival. Delay in surgical treatment is associated with higher mortality.
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Vengerovich G, Echanique KA, Park KW, Wells C, Suh JD, Lee JT, Wang MB. Retrospective Analysis of Patients With Acute Invasive Fungal Rhinosinusitis in a Single Tertiary Academic Medical Center: A 10-Year Experience. Am J Rhinol Allergy 2019; 34:324-330. [DOI: 10.1177/1945892419896233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Acute invasive fungal rhinosinusitis (AIFRS) is an aggressive, potentially fatal disease that can spread rapidly to the orbit and intracranial structures causing significant mortality and morbidity. Objective In this study, we present a 10-year experience from a tertiary academic medical center of patients presenting with AIFRS. Data on presentation, mortality rate, comorbidities, surgical, and medical management were analyzed. Methods A retrospective chart review was performed in a tertiary academic medical center of patients with AIFRS from January 2009 through February 2019. Data collected included demographics, presenting symptoms, comorbidities, immunosuppression status, endoscopic and imaging findings, orbital and intracranial complications, surgical and medical management, as well as outcomes and mortality. Results A total of 34 patients were identified. In our series, mortality was noted to be 61.8%, excluding patients who were lost to follow-up. The most common presenting symptoms included facial pain, ophthalmologic complaints, headaches, and proptosis. Only 4 of the 34 patients did not undergo surgical intervention, as they were not deemed surgical candidates; they all succumbed to their disease. Twenty-six of the 30 surgical patients (86.7%) underwent endoscopic sinus surgery, 8 underwent an open approach (26.7%), while 7 patients underwent orbital exenteration (23.3%). All patients had surgical pathology consistent with AIFRS. Fungal species isolated from culture included Aspergillus, Mucor/ Rhizopus, Candida, Cunninghamella Scedosporium boydii, Paecilomyces, and Scopulariopsis. Medical therapies included intravenous amphotericin B, caspofungin, posaconazole, voriconazole, isavuconazole, and micafungin. Conclusion AIFRS was associated with 61.8% mortality in our series of 34 patients over the past 10 years. Early diagnosis, as well as rapid and aggressive surgical and medical management, is necessary for optimal outcomes in this devastating disease.
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Affiliation(s)
- Gennadiy Vengerovich
- Department of Otolaryngology—Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Kristen A. Echanique
- Department of Otolaryngology—Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ki Wan Park
- Department of Otolaryngology—Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Christine Wells
- UCLA Statistical Consulting Group, University of California, Los Angeles, Los Angeles, California
| | - Jeffrey D. Suh
- Department of Otolaryngology—Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Jivianne T. Lee
- Department of Otolaryngology—Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Marilene B. Wang
- Department of Otolaryngology—Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Díaz Molina JP, Ramírez Argueta JJ, Ortiz Oliva RJ, Bregni RC, Bustamante Y. Results of Endoscopic Nasal Surgery in the Treatment of Invasive Fungal Sinusitis in Children with Cancer and Immunosuppression. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2019. [DOI: 10.1016/j.otoeng.2018.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ramírez Argueta JJ, Díaz Molina JP, Ortiz Oliva RJ, Carlos Bregni R, Bustamante Y. Results of endoscopic nasal surgery in the treatment of invasive fungal sinusitis in children with cancer and immunosuppression. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2019; 70:348-357. [PMID: 30773220 DOI: 10.1016/j.otorri.2018.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/20/2018] [Accepted: 09/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE to describe the results of the treatment of invasive fungal sinusitis with nasal endoscopic surgery in an immunocompromised paediatric oncological population. METHODS retrospective study of all patients diagnosed with invasive fungal sinusitis operated in the National Paediatric Oncology Unit between 2012 and 2016. Data taken from their medical history included: epidemiological characteristics, oncological diagnosis, haematological data, symptoms, tomographic studies, surgical interventions, results of pathology and cultures, medications received, complications, evolution and survival. RESULTS 18 patients were identified, 7 male and 11 female. The average age was 12 years, 13 had a diagnosis of acute lymphocytic leukemia and 5 of acute myeloid leukemia. Seventeen patients presented severe neutropenia at the time of diagnosis. The most frequently identified aetiological agent was Aspergillus in 13 patients. In 16 patients (89%) the disease was controlled with nasal endoscopic surgery. Ten patients died due to unrelated causes throughout the study. DISCUSSION AND CONCLUSIONS Invasive fungal sinusitis should be considered a medical emergency due to its high mortality. The diagnosis is based on a high index of suspicion in patients with predisposing factors (leukaemia, neutropenia, persistent fever, nasogastric tube) and endoscopic nasal evaluation. Antifungal medical treatment and aggressive nasal endoscopic surgery is indicated regardless of the patient's condition to reduce the fungal burden and associated high mortality. The treatment must be provided by a multidisciplinary team that includes paediatrics, haemato-oncology, infectology and otorhinolaryngology.
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Affiliation(s)
| | - Juan Pablo Díaz Molina
- Departamento de Otorrinolaringología, Centro Clínico de Cabeza y Cuello, Ciudad de Guatemala, Guatemala; Unidad Nacional de Oncología Padiátrica (UNOP), Ciudad de Guatemala, Guatemala.
| | - Ricardo Jose Ortiz Oliva
- Departamento de Otorrinolaringología, Centro Clínico de Cabeza y Cuello, Ciudad de Guatemala, Guatemala
| | - Roman Carlos Bregni
- Servicio de Diagnóstico Clínico y Patológico, Departamento de Otorrinolaringología, Centro Clínico de Cabeza y Cuello, Ciudad de Guatemala, Guatemala
| | - Yomara Bustamante
- Departamento de Otorrinolaringología, Centro Clínico de Cabeza y Cuello, Ciudad de Guatemala, Guatemala
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Mulvey CL, Rizzi MD, Buzi A. Predictive ability of bedside nasal endoscopy to diagnose invasive fungal sinusitis in a pediatric population. Int J Pediatr Otorhinolaryngol 2018; 115:82-88. [PMID: 30368400 DOI: 10.1016/j.ijporl.2018.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/18/2018] [Accepted: 09/18/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Invasive fungal sinusitis (IFS) is a rare but deadly clinical entity that occurs in immunocompromised patients. Diagnosis in children typically requires operative biopsies under general anesthesia, which has associated risks. Findings on bedside nasal endoscopy (BNE) can be used with history, exam, and imaging to determine the need for surgery, however, the accuracy of this tool has not been established among pediatric patients. METHODS Patients who underwent BNE for evaluation of IFS from 2008 to 2016 at the Children's Hospital of Philadelphia were identified using Current Procedural Terminology (CPT) codes. Retrospective chart analysis was performed and included underlying diagnoses, presenting signs and symptoms, imaging findings, endoscopic findings and outcomes. RESULTS Nineteen patients were identified who underwent evaluation for IFS using BNE during the period studied. Eight patients had exam findings that were concerning for IFS, including debris or crusting, darkened or pale mucosa, or copious, thick and/or purulent secretions. Immediate operative biopsies and debridement revealed IFS in six of eight patients. Eleven patients had exam findings deemed not concerning for IFS including mucosal edema, mucous without purulence, or normal findings. Six of eleven patients underwent operative biopsy despite negative endoscopy, and five were observed clinically. None of the 11 patients with negative bedside endoscopy developed IFS. CONCLUSIONS All patients with IFS had concerning exam findings on endoscopy and were treated with immediate biopsies and debridement. No patient with normal or non-concerning findings on BNE progressed to have invasive fungal sinusitis. While suspicion for IFS in immunocompromised children must remain high, BNE is feasible and useful in its assessment.
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Affiliation(s)
- Carolyn L Mulvey
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Mark D Rizzi
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Adva Buzi
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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Tekes A, Palasis S, Durand DJ, Pruthi S, Booth TN, Desai NK, Jones JY, Kadom N, Lam HFS, Milla SS, Mirsky DM, Partap S, Robertson RL, Ryan ME, Saigal G, Setzen G, Soares BP, Trout AT, Whitehead MT, Karmazyn B. ACR Appropriateness Criteria® Sinusitis-Child. J Am Coll Radiol 2018; 15:S403-S412. [DOI: 10.1016/j.jacr.2018.09.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 11/16/2022]
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Vinh D, Yim M, Dutta A, Jones JK, Zhang W, Sitton M. Pediatric invasive fungal rhinosinusitis: An investigation of 17 patients. Int J Pediatr Otorhinolaryngol 2017; 99:111-116. [PMID: 28688551 DOI: 10.1016/j.ijporl.2017.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE To investigate outcomes of pediatric patients at a single institution with invasive fungal rhinosinusitis (IFRS) and to determine variables that impact overall survival. METHODS All pediatric patients at a large tertiary children's hospital diagnosed with IFRS confirmed by surgical pathology from 2009 to 2015 were retrospectively reviewed. Demographics, underlying diseases, symptoms, antifungal therapy, absolute neutrophil count (ANC), surgical management,and outcomes were analyzed. RESULTS Seventeen patients were identified with IFRS with an average age of 8.7 years and 53% male. Hematologic malignancy was the most common (n = 13) underlying disease. The most common presenting symptoms were fever (82%) and congestion (41%). 15 patients had severe neutropenia (Absolute Neutrophil Count (ANC) < 500) within 2 weeks prior to diagnosis. The average ANC at time of diagnosis was 1420 cells/uL. 16 patients were treated with serial nasal endoscopy and debridement, while 1 patient was treated with an open approach. 16 received combination antifungals while 1 was treated with amphotericin monotherapy. The most common genus cultured was Fusarium (n = 6). The average number of surgical interventions was 3.4, with the average interval between interventions 6.2 days. 13 of 17 (76%) were cleared of IFRS. Overall survival at 6 months was 41%. CONCLUSION Pediatric IFRS is a life-threatening disease that requires a coordinated surgical and medical approach. Despite a relatively high local control rate, overall mortality remains disappointingly high, reflecting the disease's underlying pathogenesis - lack of host defense and risk of disseminated fungal infection. Further investigation is necessary to reveal optimal management with regards to antifungal therapy, surgery, and utility of labs.
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Affiliation(s)
- Daniel Vinh
- Baylor College of Medicine Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA.
| | - Michael Yim
- Baylor College of Medicine Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA
| | - Ankhi Dutta
- Baylor College of Medicine Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA; Texas Children's Hospital Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA
| | - John K Jones
- Baylor College of Medicine Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA; Texas Children's Hospital Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA
| | - Wei Zhang
- Texas Children's Hospital Department of Statistics, Houston, TX, USA
| | - Matthew Sitton
- Baylor College of Medicine Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA; Texas Children's Hospital Department of Otolaryngology-Head & Neck Surgery, Houston, TX, USA
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Abstract
BACKGROUND Immunosuppressive therapy places pediatric patients at risk of developing life-threatening sinonasal infections. Diagnosis and treatment are challenging owing to nonspecific signs and symptoms. The aim of this study was to present our department's experience with the surgical management of acute rhinosinusitis in immunosuppressed children. METHODS The records of all children with a hematologic or oncologic disease who underwent endoscopic sinus surgery (ESS) for acute rhinosinusitis from January 2005 to May 2014 were reviewed. Data were retrospectively collected on demographics, clinical and imaging characteristics, microbiology, pathology, treatment and outcome. RESULTS Thirty-four-immunosuppressed children underwent ESS for acute rhinosinusitis. Most patients had a fungal infection. Nineteen patients died at the end of follow-up; 10 deaths were infection-related. Facial swelling was the only symptom that correlated with death of infection. Relapse of the underlying disease, bone marrow transplantation, and long duration of neutropenia correlated with infection-related mortality. Fungal infection, and specifically Aspergillus, correlated with death from infection. CONCLUSIONS ESS is a safe and efficient procedure for diagnosing and treating immunosuppressed pediatric patients with acute rhinosinusitis. Early detection and aggressive medical and surgical treatment, with control of underlying risk factors, are crucial to improve outcome.
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Ergun O, Tahir E, Kuscu O, Ozgen B, Yilmaz T. Acute Invasive Fungal Rhinosinusitis: Presentation of 19 Cases, Review of the Literature, and a New Classification System. J Oral Maxillofac Surg 2017; 75:767.e1-767.e9. [DOI: 10.1016/j.joms.2016.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/02/2016] [Accepted: 11/02/2016] [Indexed: 11/16/2022]
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Smith A, Thimmappa V, Shepherd B, Ray M, Sheyn A, Thompson J. Invasive fungal sinusitis in the pediatric population: Systematic review with quantitative synthesis of the literature. Int J Pediatr Otorhinolaryngol 2016; 90:231-235. [PMID: 27729140 DOI: 10.1016/j.ijporl.2016.09.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Invasive fungal sinusitis (IFS) represents an often fatal condition within the pediatric population. In an effort to characterize demographics, treatment modalities, and prognostic factors, we performed a systematic review. METHODS We systematically reviewed EMBASE, Medline, TRIPdatabase, SCOPUS and the Cochrane database for invasive fungal nasal and sinus infections limited to individuals <18 years of age. Case series including 3 or more patients were included. Demographics, treatment and outcomes were analyzed using R Gui statistical software. RESULTS Twelve studies met inclusion criteria (103 patients). There was male preponderance of 48.5% with median age of 11 years old. Majority of patients had underlying leukemia (44.6%). Aspergillus was the predominant organism (47%). Isolated nasal findings occurred in 14% of patients and nasal findings occurred in 49% overall. Absolute neutrophil count (ANC) of immunocompromised patients was below 600 in most patients (99%). Average and median length of neutropenia was 2 weeks. All patients were prescribed amphoterocin with 50% as single medicinal therapy. Surgery occurred in 82.8% of cases. The mortality rate was 46%. Univariate analysis identified presenting with facial pain as a negative predictor of overall mortality (OR 0.296, 95% CI: 0.104-0.843, p < 0.05). CONCLUSION Mortality remains high in pediatric patients with IFS. An ANC of <600 occurred in the majority of immunocompromised patients at a duration of 2 weeks. Presenting with facial pain was a negative predictor of mortality. Many studies label this condition as invasive fungal sinusitis; however, approximately one seventh presented with only nasal findings and half overall had nasal involvement.
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Affiliation(s)
- Aaron Smith
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vikrum Thimmappa
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Brandon Shepherd
- Department of Otolaryngology, University of Mississippi, Jackson, MS, USA
| | - Meredith Ray
- University of Memphis, Department of Biostatistics, Memphis, TN, USA
| | - Anthony Sheyn
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jerome Thompson
- Department of Otolaryngology, University of Tennessee Health Science Center, Memphis, TN, USA.
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Cohn SM, Pokala HR, Siegel JD, McClay JE, Leonard D, Kwon J, Timmons CF, Winick NJ. Application of a standardized screening protocol for diagnosis of invasive mold infections in children with hematologic malignancies. Support Care Cancer 2016; 24:5025-5033. [DOI: 10.1007/s00520-016-3367-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 07/28/2016] [Indexed: 11/30/2022]
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Chermetz M, Gobbo M, Rupel K, Ottaviani G, Tirelli G, Bussani R, Luzzati R, Di Lenarda R, Biasotto M. Combined Orofacial Aspergillosis and Mucormycosis: Fatal Complication of a Recurrent Paediatric Glioma-Case Report and Review of Literature. Mycopathologia 2016; 181:723-33. [PMID: 27350324 DOI: 10.1007/s11046-016-0021-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/23/2016] [Indexed: 12/22/2022]
Abstract
Mucormycosis and aspergillosis are two opportunistic fungal infections, which can evolve into life-threatening complications. They generally affect patients with relevant risk factors such as immunocompromisation or long-term use of antibiotics or corticosteroids. Treatment usually combines medical and surgical approaches, often including extended necrosectomies, although the prognosis of generalized fungal infections is very poor. In this paper, we present the case of a 17-year-old girl affected by combined aspergillosis and mucormycosis, following treatment of a recurrent glioma. The patient was hospitalized for a suspected cellulitis of the right hemi-face, involving frontal maxillary area and the upper airways and was immediately put on intravenous antibiotic therapies; after performing nasal septum and maxillary biopsies, concomitant mucormycosis and aspergillosis were diagnosed and antimycotic therapy with liposomal B-amphotericin was administered. After evaluation by the oral surgeon and otolaryngologist, surgical cranio-facial necrosectomy was suggested, but refused by the parents of the patient. The girl died only few days later, due to a respiratory arrest. Awareness of this pathology with prompt diagnosis and early treatment may improve the outcome of these infections and reduce the mortality.
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Affiliation(s)
- Maddalena Chermetz
- Division of Oral Medicine, Dental Science Department, University of Trieste, Piazza dell'Ospitale 2, 34125, Trieste, Italy
| | - Margherita Gobbo
- Division of Oral Medicine, Dental Science Department, University of Trieste, Piazza dell'Ospitale 2, 34125, Trieste, Italy
| | - Katia Rupel
- Division of Oral Medicine, Dental Science Department, University of Trieste, Piazza dell'Ospitale 2, 34125, Trieste, Italy
| | - Giulia Ottaviani
- Division of Oral Medicine, Dental Science Department, University of Trieste, Piazza dell'Ospitale 2, 34125, Trieste, Italy
| | - Giancarlo Tirelli
- Department of Otorhinolaryngology, Head and Neck Surgery, Cattinara Hospital, Strada di Fiume 447, 34149, Trieste, Italy
| | - Rossana Bussani
- UCO Pathological Anatomy and Histopathology Unit, Cattinara Hospital, Strada di Fiume 447, 34149, Trieste, Italy
| | - Roberto Luzzati
- Infectious Diseases Unit, University Hospital, Trieste, Italy
| | - Roberto Di Lenarda
- Division of Oral Medicine, Dental Science Department, University of Trieste, Piazza dell'Ospitale 2, 34125, Trieste, Italy
| | - Matteo Biasotto
- Division of Oral Medicine, Dental Science Department, University of Trieste, Piazza dell'Ospitale 2, 34125, Trieste, Italy.
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Green KK, Barham HP, Allen GC, Chan KH. Prognostic Factors in the Outcome of Invasive Fungal Sinusitis in a Pediatric Population. Pediatr Infect Dis J 2016; 35:384-6. [PMID: 26673979 DOI: 10.1097/inf.0000000000001015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric invasive fungal sinusitis (IFS) is rare, and its prognosticators are poorly understood. The aim of this study was to determine important factors affecting outcome. METHODS A 10-year retrospective review at a tertiary academic children's hospital was performed using an International Classification of Diseases, 9th revision, and a procedure-based search after institutional review board approval. All relevant demographic and clinical information was collected. RESULTS Fourteen immune-compromised patients (male:female = 7:7, mean age = 10 years, range 2-16 years) were identified who had hematologic malignancies (11), diabetes mellitus (2) and unknown predisposing factors (1). Fungal species included Aspergillus (5), Mucor (5), Alternaria (2), Rhizopus (1) and Scopulariopsis (1). The cohort underwent an average of 6.1 (median = 5) endoscopic sinus surgeries and were treated with aggressive antifungal therapy. Four deaths occurred in the study population: 2 were attributable to IFS and 2 attributable to their underlying malignancies. There was a significant difference in the median absolute neutrophil count (ANC) at follow-up after treatment of IFS between the survival and the mortality subgroups, with ANC being 4290.5 and 169, respectively (P < 0.001). CONCLUSIONS Despite the small sample size, this study represents the largest case series in the medical literature on pediatric IFS. Age, gender, underlying cause for immunodeficiency and mycologic agent were not important prognosticators. ANC appears to be the only factor responsible for survival. The role of endoscopic sinus surgeries in survival is indeterminate.
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Affiliation(s)
- Katherine K Green
- From the Department of Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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