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Ang T, Lim W, Chaggar V, Patel S, Selva D. Radiological differentiation between bacterial orbital cellulitis and invasive fungal sino-orbital infections. Int Ophthalmol 2024; 44:319. [PMID: 38976107 PMCID: PMC11230958 DOI: 10.1007/s10792-024-03241-3] [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: 05/01/2024] [Accepted: 06/26/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE Invasive fungal orbital infections (IFOI) may be difficult to differentiate from sinogenic bacterial orbital cellulitis (OC). This study investigates the features differentiating OC from IFOI on magnetic resonance imaging (MRI). METHODS Retrospective study of adult patients with sinogenic OC and IFOI with pre-intervention MRI. Patients without post-septal involvement, non-sinogenic OC (e.g.: secondary to trauma) and poor-quality scans were excluded. Independent Sample's t test and Fisher's exact test were conducted with p < 0.05 deemed statistically significant. RESULTS Eleven cases each of OC (Mean age: 41.6 ± 18.4 years-old, Male: 10) and IFOI (Mean age: 65.0 ± 16.6 years-old, Male: 9) between 2006 and 2023. IFOI patients were older, more likely immunocompromised and had a lower mean white-cell count (p value = 0.005, 0.035 and 0.017, respectively). The ethmoid and maxillary sinuses were most commonly involved in both entities. Pre-septal and lacrimal gland involvement were more common in OC (p = 0.001 and 0.008, respectively). Infiltrative OC orbital lesions were poorly demarcated, whilst those in IFOI were expansile/mass-like invading the orbit from the adjacent paranasal sinuses. Specific IFOI features included loss-of-contrast-enhancement (LoCE) of paranasal sinus tissues with orbital extension. Extra-orbital and -sinonasal extension indicative of IFOI included contiguous skull base or pterygopalatine fossa involvement, retro-antral and masticator space stranding and vasculitis. CONCLUSION This study describes the key MRI features of IFOI including differentiating markers from OC. These specific features, such as LoCE of the paranasal and orbital soft tissues, the location and pattern of contiguous soft-tissue involvement, provide expedient identification of IFOI which necessitate early surgical intervention for microbiological confirmation of an invasive fungal pathology.
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Affiliation(s)
- Terence Ang
- The University of Adelaide, Adelaide, SA, Australia.
- Department of Ophthalmology, The Royal Adelaide Hospital, Adelaide, SA, 5000, Australia.
| | - Wanyin Lim
- The University of Adelaide, Adelaide, SA, Australia
- Department of Medical Imaging, The Royal Adelaide Hospital, Adelaide, SA, Australia
- Jones Radiology, Adelaide, SA, Australia
| | | | - Sandy Patel
- Department of Medical Imaging, The Royal Adelaide Hospital, Adelaide, SA, Australia
- Jones Radiology, Adelaide, SA, Australia
| | - Dinesh Selva
- The University of Adelaide, Adelaide, SA, Australia
- Department of Ophthalmology, The Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
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2
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Lamoth F, Prakash K, Beigelman-Aubry C, Baddley JW. Lung and sinus fungal infection imaging in immunocompromised patients. Clin Microbiol Infect 2024; 30:296-305. [PMID: 37604274 DOI: 10.1016/j.cmi.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Imaging is a key diagnostic modality for suspected invasive pulmonary or sinus fungal disease and may help to direct testing and treatment. Fungal diagnostic guidelines have been developed and emphasize the role of imaging in this setting. We review and summarize evidence regarding imaging for fungal pulmonary and sinus disease (in particular invasive aspergillosis, mucormycosis and pneumocystosis) in immunocompromised patients. OBJECTIVES We reviewed data on imaging modalities and findings used for diagnosis of invasive fungal pulmonary and sinus disease. SOURCES References for this review were identified by searches of PubMed, Google Scholar, Embase and Web of Science through 1 April 1 2023. CONTENT Computed tomography imaging is the method of choice for the evaluation of suspected lung or sinus fungal disease. Although no computed tomography radiologic pattern is pathognomonic of pulmonary invasive fungal disease (IFD) the halo sign firstly suggests an angio-invasive pulmonary aspergillosis while the Reversed Halo Sign is more suggestive of pulmonary mucormycosis in an appropriate clinical setting. The air crescent sign is uncommon, occurring in the later stages of invasive aspergillosis in neutropenic patients. In contrast, new cavitary lesions should suggest IFD in moderately immunocompromised patients. Regarding sinus site, bony erosion, peri-antral fat or septal ulceration are reasonably predictive of IFD. IMPLICATIONS Imaging assessment of the lung and sinuses is an important component of the diagnostic work-up and management of IFD in immunocompromised patients. However, radiological features signs have sensitivity and specificity that often vary according to underlying disease states. Periodic review of imaging studies and diagnostic guidelines characterizing imaging findings may help clinicians to consider fungal infections in clinical care thereby leading to an earlier confirmation and treatment of IFD.
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Affiliation(s)
- Frederic Lamoth
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Microbiology, Department of Laboratory Medicine and Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Katya Prakash
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Catherine Beigelman-Aubry
- Radiodiagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
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3
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Kline LB. Re: Idowu et al.: Magnetic resonance imaging prognostic findings for visual and mortality outcomes in acute invasive fungal rhinosinusitis (Ophthalmology. 2022;129:1313-1322). Ophthalmology 2023; 130:e36-e37. [PMID: 37390860 DOI: 10.1016/j.ophtha.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023] Open
Affiliation(s)
- Lanning B Kline
- University of Alabama School of Medicine, Birmingham, Alabama.
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4
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Khademi B, Dehghan A, Zia Z, Dehghan Y. Imaging Spectrum of Coronavirus Disease- 2019 Associated Rhino-Orbital-Cerebral Mucormycosis; From Sinonasal Inflammation to Intracranial Involvement. Acad Radiol 2023; 30:1904-1914. [PMID: 36581530 PMCID: PMC9731934 DOI: 10.1016/j.acra.2022.12.011] [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: 10/27/2022] [Revised: 11/27/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
RATIONALE AND OBJECTIVES Rhino‑Orbital‑Cerebral Mucormycosis (ROCM) is a life-threatening opportunistic fungal infection, which mostly affects immunocompromised patients. There has been a notable rise in the incidence of ROCM during the COVID-19 outbreak. In this study we described imaging characteristics of ROCM in detail, from early sinonasal inflammation to late intracranial involvement. MATERIALS AND METHODS In this retrospective study, Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) of 48 patients with proven ROCM in biopsy or culture were evaluated. All the patients had a history of COVID-19 infection within the previous three months. The imaging findings were described and the frequency of different parameters was reported. RESULTS Paranasal inflammation was detected in all the patients on imaging. The most common involved paranasal sinuses were ethmoid sinuses (97.9%). On diffusionweighted images, restricted diffusion was seen in the paranasal sinuses of 81.1% of the patients. In addition, sinus wall bone involvement was observed in 87.5% of the cases. The most common anatomical sites for extrasinus involvement were the retroantral soft tissue (89.6%) and orbital cavity (87.5%). Dacryocystitis in 50%, optic nerve inflammation in 43.2%, globe involvement in 18.9%, and trigeminal nerve involvement in 16% of the patients were detected. There was extension of inflammation through the cavernous sinuses and alongside the internal carotid arteries in 24% of the patients. CONCLUSION Characteristic imaging findings of ROCM not only play a vital role in the early diagnosis of this infection, but they also contribute to the assessment of the extension of inflammation, which is vitally important in surgical planning.
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Affiliation(s)
- Behzad Khademi
- Department of Ophthalmology, Poostchi Ophthalmology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran (B.K., Z.Z.)
| | - Alireza Dehghan
- Department of Radiology, Medical Imaging Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Zahra Zia
- Department of Ophthalmology, Poostchi Ophthalmology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran (B.K., Z.Z.)
| | - Yasamin Dehghan
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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5
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Pérez MA, Martínez L, Bravo J, Rodríguez B, Quintero P, Moncada P. Infection due to Aspergillus flavus and Rhizopus oryzae complex in a patient with diabetes mellitus. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:27-36. [PMID: 37167471 PMCID: PMC10470490 DOI: 10.7705/biomedica.6358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 03/04/2023] [Indexed: 05/13/2023]
Abstract
Fungal sinusitis is a pathology that can occur in patients with diabetes mellitus and be associated with a hyperglycemic crisis. It is an aggressive entity with local complications that include involvement of the orbit or the central nervous system, and vascular involvement. Despite surgical and antifungal treatment, mortality raises up to 75%. We report the case of a female patient with a diagnosis of diabetic ketoacidosis and signs of unilateral ophthalmoplegia, which led to the study with magnetic resonance imaging of the central nervous system, finding signs of sinusitis, meningitis, and cerebritis. Initial microbiological studies were negative, and biomarkers such as serum galactomannan and Cryptococcus antigen were also negative. After surgical management and the identification of Aspergillus flavus and Rhizopus spp. in sinus tissue, the patient received treatment with posaconazole and after two months of follow-up she presented clinical improvement. Dual fungal infection and infection by A. flavus are uncommon and clinically relevant entities, with no cases previously reported in our country, therefore this corresponds to a case of clinical interest.
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Affiliation(s)
| | - Luisa Martínez
- Departamento de Microbiología, Fundación Valle del Lili, Cali, Colombia.
| | - Juan Bravo
- Departamento de Patología, Fundación Valle del Lili, Cali, Colombia.
| | - Brenda Rodríguez
- Departamento de Medicina Interna, Fundación Valle del Lili, Cali, Colombia.
| | - Paola Quintero
- Departamento de Medicina Interna, Fundación Valle del Lili, Cali, Colombia.
| | - Pablo Moncada
- Departamento de Infectología, Fundación Valle del Lili, Cali, Colombia.
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6
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Baba A, Kurokawa R, Kurokawa M, Reifeiss S, Policeni BA, Ota Y, Srinivasan A. Advanced imaging of head and neck infections. J Neuroimaging 2023. [PMID: 36922159 DOI: 10.1111/jon.13099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/17/2023] Open
Abstract
When head and neck infection is suspected, appropriate imaging contributes to treatment decisions and prognosis. While contrast-enhanced CT is the standard imaging modality for evaluating head and neck infections, MRI can better characterize the skull base, intracranial involvement, and osteomyelitis, implying that these are complementary techniques for a comprehensive assessment. Both CT and MRI are useful in the evaluation of abscesses and thrombophlebitis, while MRI is especially useful in the evaluation of intracranial inflammatory spread/abscess formation, differentiation of abscess from other conditions, evaluation of the presence and activity of inflammation and osteomyelitis, evaluation of mastoid extension in middle ear cholesteatoma, and evaluation of facial neuritis and labyrinthitis. Apparent diffusion coefficient derived from diffusion-weighted imaging is useful for differential diagnosis and treatment response of head and neck infections in various anatomical sites. Dynamic contrast-enhanced MRI perfusion may be useful in assessing the activity of skull base osteomyelitis. MR bone imaging may be of additional value in evaluating bony structures of the skull base and jaw. Dual-energy CT is helpful in reducing metal artifacts, evaluating deep neck abscess, and detecting salivary stones. Subtraction CT techniques are used to detect progressive bone-destructive changes and to reduce dental amalgam artifacts. This article provides a region-based approach to the imaging evaluation of head and neck infections, using both conventional and advanced imaging techniques.
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Affiliation(s)
- Akira Baba
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryo Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mariko Kurokawa
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott Reifeiss
- Department of Radiology, Roy Caver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Bruno A Policeni
- Department of Radiology, Roy Caver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Yoshiaki Ota
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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7
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Diagnostic and therapeutic strategies of acute invasive fungal rhinosinusitis. Asian J Surg 2023; 46:58-65. [PMID: 35589479 DOI: 10.1016/j.asjsur.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/19/2022] [Accepted: 05/06/2022] [Indexed: 12/16/2022] Open
Abstract
Acute invasive fungal rhinosinusitis (AIFR) is a rare disease, but the prognosis is by no means ideal. Pathologically, fungal infection is not only located in the sinus cavity, but also invades the sinus mucosa and bone wall, the surrounding structures and tissues such as the orbit and anterior skull base are often compromised and are accompanied with intracranial and extracranial complications. Despite decades of efforts, acute invasive fungal rhinosinusitis remains a devastating disease, the mortality of the disease continues to hover around 50%. The main impediments to improving the prognosis of acute invasive fungal rhinosinusitis are the difficulties of early diagnosis and the rapid reversal of immune insufficiency. Moreover, aggressive surgery combined with systemic antifungal therapy are significant positive prognostic factors as well. Progress and standardization of AIFR treatment protocols have been limited by the scarcity of the disease and the absence of published randomized studies. Therewith, how to improve the therapeutic outcome and reduce the mortality rate has always been a challenging clinical discussion. We have summarized the relevant case series and literature from the recent years, management with optimal diagnostic and curative strategies are reviewed.
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8
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Agarwal S, Gautam R, Kumar J, Garg A, Khurana N, Meher R, Wadhwa V, Goel R, Arora R. COVID-Associated Sinonasal Mucormycosis: Radiological Pathological Correlation and Prognostic Value of MR Imaging. Indian J Radiol Imaging 2022; 33:46-52. [PMID: 36855711 PMCID: PMC9968527 DOI: 10.1055/s-0042-1759639] [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] [Indexed: 12/23/2022] Open
Abstract
Purpose Our aim was to assess the sinonasal magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) in coronavirus disease (COVID)-associated mucormycosis (CAM) and to correlate these with histopathology and patient outcome in terms of duration of hospital stay and survival at 10 weeks. Methods Twenty patients with histopathologically confirmed sinonasal CAM underwent MRI (including postcontrast T1-weighted and diffusion-weighted imaging). Histopathological findings (presence of coagulative necrosis, granulomatous reaction, and fungal burden) were recorded and all patients were followed up at 6 and 10 weeks. Statistical analysis was done using chi-square test and Fischer's exact test. Results Enhancement patterns seen in our subjects included homogeneous, heterogeneous, and lack of contrast enhancement (LOC), with LOC being the most common (65%). Diffusion restriction was found in 90% patients. Statistically significant correlation was found between LOC pattern and presence of coagulative necrosis ( p -value = 0.007), extent of fungal hyphae ( p -value = 0.047), and duration of hospital stay ( p -value = 0.004). Restricted diffusion was also seen to correlate with a high fungal load ( p -value = 0.007). Conclusion Our study describes the MRI findings of AIFRS in CAM and highlights the imaging features which may be surrogate markers for coagulative necrosis and fungal burden.
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Affiliation(s)
- Sheetal Agarwal
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Richa Gautam
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Jyoti Kumar
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India,Address for correspondence Jyoti Kumar, MD Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical CollegeJawaharlal Nehru Marg, New Delhi 110002India
| | - Anju Garg
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Nita Khurana
- Department of Pathology, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Ravi Meher
- Department of Otorhinolaryngology, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Vikram Wadhwa
- Department of Otorhinolaryngology, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Ruchi Goel
- Department of Ophthalmology, Guru Nanak Eye Center and Maulana Azad Medical College, New Delhi, India
| | - Ritu Arora
- Department of Ophthalmology, Guru Nanak Eye Center and Maulana Azad Medical College, New Delhi, India
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9
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Idowu OO, Soderlund KA, Laguna B, Ashraf DC, Arnold BF, Grob SR, Winn BJ, Russell MS, Kersten RC, Dillon WP, Vagefi MR. Magnetic Resonance Imaging Prognostic Findings for Visual and Mortality Outcomes in Acute Invasive Fungal Rhinosinusitis. Ophthalmology 2022; 129:1313-1322. [PMID: 35768053 DOI: 10.1016/j.ophtha.2022.06.020] [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: 03/31/2022] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 10/31/2022] Open
Abstract
PURPOSE To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS). DESIGN Retrospective cohort study. PARTICIPANTS Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020. METHODS A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality. MAIN OUTCOME MEASURE Identification of initial, preintervention MRI findings associated with visual and mortality outcomes. RESULTS The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; P < 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001). CONCLUSIONS Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality.
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Affiliation(s)
- Oluwatobi O Idowu
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Karl A Soderlund
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Benjamin Laguna
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Davin C Ashraf
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Benjamin F Arnold
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Seanna R Grob
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Bryan J Winn
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Matthew S Russell
- Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Robert C Kersten
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - William P Dillon
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - M Reza Vagefi
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
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10
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Hagiwara M, Policeni B, Juliano AF, Agarwal M, Burns J, Dubey P, Friedman ER, Gule-Monroe MK, Jain V, Lam K, Patino M, Rath TJ, Shian B, Subramaniam RM, Taheri MR, Zander D, Corey AS. ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update. J Am Coll Radiol 2022; 19:S175-S193. [PMID: 35550800 DOI: 10.1016/j.jacr.2022.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 11/26/2022]
Abstract
This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Mari Hagiwara
- Neuroradiology Fellowship Program Director, New York University Langone Health, New York, New York.
| | - Bruno Policeni
- Panel Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amy F Juliano
- Panel Vice-Chair and Director of Research and Academic Affairs, Mass Eye and Ear, Harvard Medical School, Boston, Massachusetts; ACR Chair NI-RADS Committee
| | - Mohit Agarwal
- Fellowship Program Director, Froedtert Memorial Lutheran Hospital Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Judah Burns
- Residency Program Director, Diagnostic Radiology, Montefiore Medical Center, Bronx, New York
| | - Prachi Dubey
- Houston Methodist Hospital, Houston, Texas; Alternate Councilor, Texas Radiological Society; and Member, ACR Neuroradiology Commission
| | | | - Maria K Gule-Monroe
- Medical Director of Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vikas Jain
- Assistant Program Director of Radiology Residency Program, MetroHealth Medical Center, Cleveland, Ohio
| | - Kent Lam
- Eastern Virginia Medical School, Norfolk, Virginia; Rhinology and Paranasal Sinus Committee Member, American Academy of Otolaryngology - Head and Neck Surgery; Consultant to the Board, American Rhinologic Society
| | - Maria Patino
- University of Texas Health Science Center, Houston, Texas
| | - Tanya J Rath
- Division Chair of Neuroradiology, Education Director of Neuroradiology, Mayo Clinic Arizona, Phoenix, Arizona; President of the Eastern Neuroradiological Society
| | - Brian Shian
- Primary Care Physician, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Rathan M Subramaniam
- University of Otago, Dunedin, Otepoti, New Zealand; Co-Chair, ACR Committee on Practice Parameters and Technical Standards - Nuclear Medicine and Molecular Imaging
| | - M Reza Taheri
- Director of Neuroradiology, George Washington University Hospital, Washington, District of Columbia
| | - David Zander
- Chief of Head and Neck Radiology, University of Colorado Denver, Denver, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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11
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Shareef M, Ghosn Y, Khdhir M, El Annan T, Alam R, Hourani R. Critical infections in the head and neck: A pictorial review of acute presentations and complications. Neuroradiol J 2022:19714009211059122. [PMID: 35188822 DOI: 10.1177/19714009211059122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Non-traumatic head and neck emergencies include several disease processes such as infectious, inflammatory, and malignant. Infections are among the most common pathological processes that affect the head and neck, and are particularly important due to their acute, severe, and potentially life-threatening nature. Radiologists need to be well acquainted with these entities because any delay or misdiagnosis can lead to significant morbidity and mortality. Having a general understanding of such diseases is crucial, their prevalence, clinical presentation, common causative pathogens, route of spread, potential complications, and multimodality radiological appearance. Furthermore, understanding the relevant anatomy of the region, including the various fascial planes and spaces, is essential for radiologists for accurate image interpretation and assessment of potential complications. Our aim is to review the most common severe infections affecting the head and neck as well as other rare but potentially life-threatening infections. We will also describe their imaging features while focusing on the anatomy of the regions involved and describing their potential complications and treatment options.
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Affiliation(s)
| | - Youssef Ghosn
- Department of Diagnostic Radiology, 66984American University of Beirut, Lebanon
| | - Mihran Khdhir
- Department of Diagnostic Radiology, 66984American University of Beirut, Lebanon
| | - Tamara El Annan
- Department of Diagnostic Radiology, 66984American University of Beirut, Lebanon
| | - Raquelle Alam
- Department of Diagnostic Radiology, 66984American University of Beirut, Lebanon
| | - Roula Hourani
- Department of Diagnostic Radiology, 66984American University of Beirut, Lebanon
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Elmokadem AH, Bayoumi D, Mansour M, Ghonim M, Saad EA, Khedr D. COVID-19-associated acute invasive fungal sinusitis: Clinical and imaging findings. J Neuroimaging 2022; 32:676-689. [PMID: 35043509 DOI: 10.1111/jon.12967] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/23/2021] [Accepted: 01/02/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND PURPOSE The purpose is to provide a comprehensive report describing the clinical and imaging features of Coronavirus disease 2019 (COVID-19)-related acute invasive fungal sinusitis (AIFS) and associated comorbidities. METHODS A retrospective study was conducted on 25 patients (12 males and 13 females, mean age of 53.9±9.1 years). All patients had positive polymerase chain reaction test for COVID-19 and histopathological proof of AIFS. Patients underwent computed tomography (CT) and magnetic resonance examinations to assess sinonasal, orbital, and cranial spread. RESULTS The most prevalent comorbidity among the study cohort was diabetes mellitus (DM). Twenty-one patients (84%) were diagnosed in the post-COVID-19 period after hospital discharge, with a mean interval of 19.1±9.2 days. Steroid treatment was given to 19 patients (76%). Orbital manifestations were the presenting symptoms in all patients, followed by facial edema, nasal discharge, and neurological symptoms. Sinonasal involvement ranged from mucosal thickening to complete sinus opacification by a predominant isodensity on CT, low T1, and high T2 signal intensity with variable enhancement patterns. Twenty-four patients had a unilateral orbital extension, and 12 patients showed signs of intracranial extension. Bone involvement was detected in 16 patients (64%). Follow-up scans in 18 patients (72%) showed rapid progression of the disease. Eight patients (32%) died, six from neurological complications and two from severe respiratory failure. CONCLUSION Steroids, DM, and severe COVID-19 are the major risk factors of AIFS in the post-COVID-19 era. Imaging scans in all patients revealed different sinonasal, facial, orbital features, and intracranial involvement with rapid progression of the findings on follow-up scans.
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Affiliation(s)
- Ali H Elmokadem
- Department of Radiology, Mansoura University, Mansoura, Egypt.,Department of Radiology, Farwaniya Hospital, Sabah Al Nasser, Kuwait
| | - Dalia Bayoumi
- Department of Radiology, Mansoura University, Mansoura, Egypt
| | - Manar Mansour
- Department of Radiology, Mansoura University, Mansoura, Egypt
| | - Mahitab Ghonim
- Department of Radiology, Mansoura University, Mansoura, Egypt
| | - Eman A Saad
- Department of Pathology, Mansoura University, Mansoura, Egypt
| | - Doaa Khedr
- Department of Radiology, Mansoura University, Mansoura, Egypt
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Imaging of COVID-19-associated craniofacial mucormycosis: a black and white review of the "black fungus". Clin Radiol 2021; 76:812-819. [PMID: 34364672 PMCID: PMC8316064 DOI: 10.1016/j.crad.2021.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/20/2021] [Indexed: 12/26/2022]
Abstract
A subset of diabetic COVID-19 patients treated with steroids, oxygen, and/or prolonged intensive care admission develop rhino-orbito-cerebral mucormycosis. Radiologists must have a high index of suspicion for early diagnosis, which prompts immediate institution of antifungal therapy that limits morbidity and mortality. Assessment of disease extent by imaging is crucial for planning surgical debridement. Complete debridement of necrotic tissue improves survival. Imaging features reflect the angioinvasive behaviour of fungal hyphae from the Mucoraceae family, which cause necrotising vasculitis and thrombosis resulting in extensive tissue infarction. Contrast-enhanced magnetic resonance imaging (MRI) is the imaging technique of choice. The classic “black turbinate” on contrast-enhanced imaging represents localised invasive fungal rhinosinusitis (IFRS). A striking radiological feature of disseminated craniofacial disease is non-enhancing devitalised and necrotic soft tissue at the orbits and central skull base. Sinonasal and extrasinonasal non-enhancing lesions in IFRS are secondary to coagulative necrosis induced by fungal elements. Multicompartmental and extrasinonasal tissue infarction is possible without overt bone involvement and caused by the propensity of fungal elements to disseminate from the nasal cavity via perineural and perivascular routes. Fungal vasculitis can result in internal carotid artery occlusion and cerebral infarction. Remnant non-enhancing lesions after surgical debridement portend a poor prognosis. Assessment for the non-enhancing MRI lesion is crucial, as it is a sole independent prognostic factor for IFRS-specific mortality. In this review, we describe common and uncommon imaging presentations of biopsy-proven rhino-orbito-cerebral mucormycosis in a cohort of nearly 40 COVID-19 patients.
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Affiliation(s)
- Cyrine Drissi
- Department of Neuroradiology, National Institute of Neurology of Tunis; Faculty of Medicine of Tunis, University Tunis El Manar, Tunisia.
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15
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Sreshta K, Dave TV, Varma DR, Nair AG, Bothra N, Naik MN, Sistla SK. Magnetic resonance imaging in rhino-orbital-cerebral mucormycosis. Indian J Ophthalmol 2021; 69:1915-1927. [PMID: 34146057 PMCID: PMC8374747 DOI: 10.4103/ijo.ijo_1439_21] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Coronavirus disease-associated mucormycosis (CAM) is an established clinical entity in India. In the past 4 months, there has been a sharp upsurge in the number of CAM cases in most parts of the country. Early diagnosis can be lifesaving. Magnetic resonance imaging (MRI) imaging remains the corner stone of management in patients with ROCM. This review discussed the utility of MRI imaging in ROCM with an emphasis on the ideal MRI protocol in a suspected case of ROCM, the pathways of spread of infection, the classic diagnostic features, MRI for staging of the disease, MRI for prognostication, MRI for follow up, and imaging features of common differentials in ROCM. The pit falls of MRI imaging and a comparison of CT and MRI imaging in ROCM are discussed. The clinical interpretation of areas of contrast uptake and those of necrosis and its relevance to treatment are discussed. This review aims to familiarize every member of the multidisciplinary team involved in managing these patients to be able to interpret the findings on MRI in ROCM.
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Affiliation(s)
- Kanduri Sreshta
- Department of Neuroradiology, Citi Neuro Centre, Hyderabad, Telangana, India
| | - Tarjani Vivek Dave
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Dandu Ravi Varma
- Department of Neuroradiology, Citi Neuro Centre, Hyderabad, Telangana, India
| | - Akshay Gopinathan Nair
- Aditya Jyot Eye Hospital, Mumbai; Advanced Eye hospital and Institute, Navi Mumbai, India
| | - Nandini Bothra
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Milind N Naik
- Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India
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16
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Image findings in patients with chronic invasive fungal infection of paranasal sinuses. J Neuroradiol 2021; 48:325-330. [PMID: 33639140 DOI: 10.1016/j.neurad.2021.02.005] [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: 09/06/2020] [Revised: 11/09/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES More clear classification of chronic invasive fungal infection of paranasal sinuses in the clinical presentation, radiologic findings, and pathology is needed. To describe the imaging findings of patients with chronic invasive fungal sinusitis (CIFS) and chronic granulomatous invasive fungal sinusitis (CGIFS). METHODS Eleven patients with CIFS or CGIFS between January 2014 and July 2019 were included in this retrospective study. The demographic, pathologic, and imaging characteristics of the included patients were reviewed by rhinologist, pathologist, and radiologist, respectively. In terms of imaging analysis, overall lesions were categorized as diffuse infiltrative and mass-forming patterns. RESULTS Among eleven patients, ten patients were aged ≥ 60 years (mean age 74.2 years) and nine had hypertension and/or diabetes mellitus. Aspergillus species were the most common pathogens (82%). Of the seven patients with CIFS, five (71%) had diffuse infiltrative patterns and two (29%) had mass-forming patterns, whereas all four patients (100%) with CGIFS had a mass forming pattern. All 11 patients showed both bony erosion and sclerosis. Almost all proven pathologic sites showed predominantly intermediate to high signal intensity on T1WI. CONCLUSIONS CIFS or CFIFS showed chronic course of rhinosinusitis in the patients with old age, imaging findings of bone erosion and sclerosis, and imaging patterns of diffuse infiltration or mass formation.
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Lagos AE, García-Huidobro FG, Sepúlveda V, Cruz JP, González C, Callejas CA. Determination of variables for a more accurate diagnostic approach in suspected acute invasive fungal rhinosinusitis: A non-concurrent cohort study. Clin Otolaryngol 2021; 46:775-781. [PMID: 33548105 DOI: 10.1111/coa.13734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/04/2021] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe a group of patients with suspected acute invasive fungal rhinosinusitis (AIFRS) diagnosis, and identify factors associated with a greater risk of presenting this disease. DESIGN Non-concurrent cohort study. SETTING A single-centre non-concurrent follow-up of patients with suspected AIFRS between August 2015 and July 2018. PARTICIPANTS 50 inpatients referred due to suspected AIFRS at Hospital Clínico Universidad Católica based on the association of a predisposing factor (neutropenia/immunodeficiency/poorly controlled diabetes) with fever of unknown origin. MAIN OUTCOME MEASURE The primary outcome was AIFRS diagnosis, defined as a concordant tissue biopsy. RESULTS Acute invasive fungal rhinosinusitis was confirmed in 18% (9/50) of the evaluated patients. AIFRS was significantly associated with a positive galactomannan (P = .04), and a paranasal sinus MRI with lack of contrast enhancement (LoCE) (P = .04) orbit compromise (P = .03) or global extrasinusal extension (P = .04). LoCE and extrasinusal extension in the paranasal sinus/brain MRI were risk factors for AIFRS (OR 16; CI 1.2-210.6 and OR 12.75; CI 1.3-128.8, respectively). Conversely, a nasal endoscopy showing healthy mucosa was identified as a protective factor for AIFRS (OR 0.06; CI 0.007-0.57). CONCLUSIONS In patients with suspected AIFRS, we identified laboratory and radiologic variables associated with the disease, which may help for a more accurate diagnostic algorithm and approach in this population.
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Affiliation(s)
- Antonia E Lagos
- Department of Otolaryngology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Valeria Sepúlveda
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Pablo Cruz
- Department of Radiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia González
- Department of Otolaryngology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudio A Callejas
- Department of Otolaryngology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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19
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Harreld JH, Kaufman RA, Kang G, Maron G, Mitchell W, Thompson JW, Srinivasan A. The use of imaging to identify immunocompromised children requiring biopsy for invasive fungal rhinosinusitis. Pediatr Blood Cancer 2020; 67:e28676. [PMID: 32860662 DOI: 10.1002/pbc.28676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Children with severe immunocompromise due to cancer therapy or hematopoietic cell transplant are at risk both for potentially lethal invasive fungal rhinosinusitis (IFRS), and for complications associated with gold-standard biopsy diagnosis. We investigated whether early imaging could reliably identify or exclude IFRS in this population, thereby reducing unnecessary biopsy. METHODS We reviewed clinical/laboratory data and cross-sectional imaging from 31 pediatric patients evaluated for suspicion of IFRS, 19 without (age 11.8 ± 5.4 years) and 12 with proven IFRS (age 11.9 ± 4.6 years). Imaging examinations were graded for mucosal thickening (Lund score), for fungal-specific signs (FSS) of bone destruction, extra-sinus inflammation, and nasal mucosal ulceration. Loss of contrast enhancement (LoCE) was assessed separately where possible. Clinical and imaging findings were compared with parametric or nonparametric tests as appropriate. Diagnostic accuracy was assessed by receiver operating characteristic (ROC) analysis. Positive (+LR) and negative likelihood ratios (-LR) and probabilities were calculated. RESULTS Ten of 12 patients with IFRS and one of 19 without IFRS had at least one FSS on early imaging (83% sensitive, 95% specific, +LR = 15.83, -LR = 0.18; P < .001). Absolute neutrophil count (ANC) ≤ 200/mm3 was 100% sensitive and 58% specific for IFRS (+LR = 2.38, -LR = 0; P = .001). Facial pain was the only discriminating symptom of IFRS (P < .001). In a symptomatic child with ANC ≤ 200/m3 , the presence of at least one FSS indicated high (79%) probability of IFRS; absence of FSS suggested low (<4%) probability. CONCLUSION In symptomatic, severely immunocompromised children, the presence or absence of fungal-specific imaging findings may effectively rule in or rule out early IFRS, potentially sparing some patients the risks associated with biopsy.
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Affiliation(s)
- Julie H Harreld
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Robert A Kaufman
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Guolian Kang
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Gabriela Maron
- Department of Infectious Disease, St Jude Children's Research Hospital, Memphis, Tennessee
| | - William Mitchell
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jerome W Thompson
- Department of Otolaryngology, University of Tennessee Health Sciences Center; Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, Tennessee
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Poyiadji N, Li T, Craig J, Rheinboldt M, Patel S, Marin H, Griffith B. Imaging Findings in Non-Neoplastic Sinonasal Disease: Review of Imaging Features With Endoscopic Correlates. Curr Probl Diagn Radiol 2020; 50:856-866. [PMID: 33039195 DOI: 10.1067/j.cpradiol.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 12/14/2022]
Abstract
Non-neoplastic sinonasal disease is common and imaging often plays an important role in establishing the proper diagnosis, guiding clinical management, and evaluating for complications. Both computed tomography and magnetic resonance imaging are commonly employed in the imaging evaluation and it is important to understand the imaging characteristics of the unique types of pathology affecting the sinonasal cavities. This article reviews a variety of infectious, inflammatory, and other non-neoplastic sinonasal pathologies, highlighting imaging features that aid in their differentiation.
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Affiliation(s)
- Neo Poyiadji
- Department of Radiology, Henry Ford Health System, Detroit, MI
| | - Ting Li
- Department of Radiology, Henry Ford Health System, Detroit, MI
| | - John Craig
- Department of Otolaryngology, Henry Ford Health System, Detroit, MI
| | | | - Suresh Patel
- Department of Radiology, Henry Ford Health System, Detroit, MI
| | - Horia Marin
- Department of Radiology, Henry Ford Health System, Detroit, MI
| | - Brent Griffith
- Department of Radiology, Henry Ford Health System, Detroit, MI.
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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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22
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Li Z, Wang X, Jiang H, Qu X, Wang C, Chen X, Chong VFH, Zhang L, Xian J. Chronic invasive fungal rhinosinusitis vs sinonasal squamous cell carcinoma: the differentiating value of MRI. Eur Radiol 2020; 30:4466-4474. [PMID: 32279114 DOI: 10.1007/s00330-020-06838-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/07/2020] [Accepted: 03/25/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate MRI features in discriminating chronic invasive fungal rhinosinusitis (CIFRS) from sinonasal squamous cell carcinomas (SNSCC). METHODS MRI findings of 33 patients with CIFRS and 47 patients with SNSCC were retrospectively reviewed and compared. Multivariate logistic regression analysis was performed to identify significant imaging features in distinguishing between CIFRS and SNSCC. The ROC curves and the AUC were used to evaluate diagnostic performance. RESULTS There were significant differences in cavernous sinus involvement (p < 0.001), sphenoid sinus involvement (p < 0.001), meningeal involvement (p = 0.024), T2 signal intensity (p = 0.006), and enhancement pattern (p < 0.001) between CIFRS and SNSCC. Multivariate logistic regression analysis identified cavernous sinus involvement (odds ratio [OR] = 0.06, 95% confidence interval [95% CI] = 0.02-0.20) and sphenoid sinus involvement (OR = 0.14, 95% CI = 0.05-0.45) as significant indicators for CIFRS and T2 isointensity to gray matter (OR = 4.44, 95% CI = 1.22-16.22) was a significant indicator for SNSCC. ROC curve analysis showed the AUC from a combination of three imaging features was 0.95 in differentiating CIFRS and SNSCC. CONCLUSIONS MRI showed significant differences between CIFRS and SNSCC features. In immunocompromised patients, a sinonasal hypointense mass on T2WI with septal enhancement or loss of contrast enhancement, and involvement of cavernous sinus, sphenoid sinus, and meninges strongly suggest CIFRS. KEY POINTS • Chronic invasive fungal rhinosinusitis (CIFRS) is often difficult to distinguish from sinonasal squamous cell carcinomas (SNSCC) in clinical practice. • Cavernous sinus and sphenoid sinus involvement appear to be significant indicators for CIFRS. T2 isointensity to gray matter appears to be a significant indicator for SNSCC. • Loss of contrast enhancement and septal enhancement can be used to distinguish CIFRS from SNSCC with a high degree of specificity.
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Affiliation(s)
- Zheng Li
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, No. 1, DongJiaoMinXiang Street, DongCheng District, Beijing, 100730, China
| | - Xiao Wang
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, No. 1, DongJiaoMinXiang Street, DongCheng District, Beijing, 100730, China
| | - Hong Jiang
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, No. 1, DongJiaoMinXiang Street, DongCheng District, Beijing, 100730, China
| | - Xiaoxia Qu
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, No. 1, DongJiaoMinXiang Street, DongCheng District, Beijing, 100730, China
| | - Chengshuo Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, 100005, China
| | - Xiaohong Chen
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, 100005, China
| | - Vincent Fook-Hin Chong
- Department of Diagnostic Imaging, National University Hospital, National University of Singapore, Singapore, 117094, Singapore
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China. .,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, 100005, China. .,Department of Allergy, Beijing TongRen Hospital, Capital Medical University, No. 1, DongJiaoMinXiang Street, DongCheng District, Beijing, 100730, China.
| | - Junfang Xian
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, No. 1, DongJiaoMinXiang Street, DongCheng District, Beijing, 100730, China.
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Marie E, Navallas M, Navarro OM, Punnett A, Shammas A, Gupta A, Chami R, Shroff MM, Vali R. Posttransplant Lymphoproliferative Disorder in Children: A 360-degree Perspective. Radiographics 2019; 40:241-265. [PMID: 31834850 DOI: 10.1148/rg.2020190103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
An earlier incorrect version of this article appeared online. This article was corrected on December 17, 2019.
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Affiliation(s)
- Eman Marie
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - María Navallas
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Oscar M Navarro
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Angela Punnett
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amer Shammas
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aaryan Gupta
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rose Chami
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manohar M Shroff
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Reza Vali
- From the Departments of Medical Imaging (E.M., M.N., O.M.N., A.S., M.M.S., R.V.), Pediatrics (A.P.), and Laboratory Medicine and Pathobiology (R.C.), University of Toronto, Toronto, Ontario, Canada; and the Department of Diagnostic Imaging (E.M., M.N., O.M.N., A.G., M.M.S.), Division of Pediatric Hematology/Oncology, Department of Pediatrics (A.P.), Division of Nuclear Medicine, Department of Diagnostic Imaging (A.S., R.V.), and Department of Pediatric Pathology and Laboratory Medicine (R.C.), The Hospital for Sick Children, Toronto, Ontario, Canada
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Diagnosis and Treatment of Acute Invasive Fungal Sinusitis in Cancer and Transplant Patients. Curr Infect Dis Rep 2019; 21:53. [PMID: 31773398 DOI: 10.1007/s11908-019-0707-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Modern advances in oncologic and end-organ therapies have led to an increase in immunocompromised patients and a corresponding rise in acute invasive fungal sinusitis (AIFS). Here, we present a comprehensive medical and surgical approach to the diagnosis and management of immunocompromised cancer and transplant patients with AIFS. RECENT FINDINGS Aspergillus and Mucorales are the most common fungi to cause AIFS, though atypical fungal pathogens have been implicated particularly among patients on azole prophylaxis. Symptoms present in the majority of AIFS cases include fever, nasal congestion, and facial swelling. Nasal endoscopy and radiology are adjuncts to clinical exam with the gold standard diagnostic test still being histopathology, though molecular testing such as panfungal PCR is playing a larger role. The treatment of AIFS requires surgery, antifungal therapy, and reversal of immunosuppression. We recommend initiation of liposomal amphotericin B as an empiric therapy for AIFS, transitioned to targeted therapy when/if a fungal pathogen is identified. Goals of surgery include diagnostic sampling and debridement of necrotic tissue. Equally, if not more important, is reversal of underlying immune suppression. Immune-stimulating therapies hold promise for reducing mortality, but require additional study. Despite improvements in medical and surgical management of AIFS, mortality continues to approach 50%. Early diagnosis of this disease entity followed by aggressive surgical and medical management are important, including reversal of the underlying immunosuppression.
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Invasive and Non-Invasive Fungal Rhinosinusitis-A Review and Update of the Evidence. ACTA ACUST UNITED AC 2019; 55:medicina55070319. [PMID: 31261788 PMCID: PMC6681352 DOI: 10.3390/medicina55070319] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022]
Abstract
Fungal infections are a subset of infectious processes that an otolaryngologist is required to be familiar with. They can be encountered in otology, rhinology and head and neck surgery. The presence of fungal rhinosinusitis is well recognised by otolaryngologists, but the classifications and appropriate management are not so well understood. The prevalence of fungal sinus disease is thought to be have been increasing in recent decades There is speculation that this may be due to increased awareness, antibiotic overuse and increased use of immunosuppressant medications. Added to this, there has been a large amount published on the role of fungi as a causative organism in chronic rhinosinusitis. Given the importance of fungal rhinosinusitis in clinical practice, we aim to review the classification and current management strategies based on up-to-date literature.
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Han Q, Escott EJ. The Black Turbinate Sign, A Potential Diagnostic Pitfall: Evaluation of the Normal Enhancement Patterns of the Nasal Turbinates. AJNR Am J Neuroradiol 2019; 40:855-861. [PMID: 31000527 DOI: 10.3174/ajnr.a6037] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/18/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Lack of enhancement of a nasal turbinate on MR imaging, known as the black turbinate, has been reported as a finding highly suggestive of invasive fungal rhinosinusitis in immunocompromised patients. Our purpose was to investigate the normal enhancement pattern of nasal turbinates and to determine whether a black turbinate occurs in patients without invasive fungal rhinosinusitis and, if so, to distinguish differentiating features from pathologic enhancement. MATERIALS AND METHODS We examined patient medical records and available MR imaging, which included most nasal turbinates in more than 1 sequence. Imaging was performed with contrast, either with or without fat saturation, in patients without invasive fungal rhinosinusitis. All MR images were evaluated for a turbinate enhancement pattern and the presence of nonenhancing areas. RESULTS After we applied the exclusion criteria, 75 MR images from each group, with and without fat saturation, were included. Overall, the frequency of observed nonenhancing portions of turbinates, ie, black turbinates, was 30%. Most observed black turbinates were located in the posterior portion of inferior turbinates. Tiny areas of nonenhancement within turbinates were also a common finding. CONCLUSIONS A black turbinate is not uncommon on MR images in immunocompetent patients who have no chance of having invasive fungal rhinosinusitis. Benign turbinate nonenhancement improves over subsequent series, has preserved thin peripheral enhancement, and often has thin internal septa. Knowledge of this normal pattern of nasal turbinate enhancement can aid in the differentiation of the benign black turbinate in immunocompetent patients from the pathologic black turbinate seen in patients with invasive fungal rhinosinusitis.
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Affiliation(s)
- Q Han
- From the Departments of Radiology (Q.H.)
| | - E J Escott
- Radiology and Otolaryngology-Head and Neck Surgery (E.J.E.), University of Kentucky, Lexington, Kentucky
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