Acute invasive fungal rhinosinusitis: our experience with 19 patients

Invasive fungal rhinosinusitis: current evidence and research opportunities

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.

Post COVID-19 Mucormycosis-The Horizon

OBJECTIVE

Acute Invasive Fungal Rhinosinusitis is a rare condition which recently has gained attention due to its increased occurrence in the post COVID-19 patients past the second wave. The current study retrospectively evaluates the occurrence of Acute Invasive Fungal Rhinosinusitis (Mucormycosis) in post COVID-19 (Corona Virus Disease-19) patients.

METHODS

A descriptive study included patients diagnosed with Acute Invasive Fungal Rhinosinusitis (Mucormycosis) after recent COVID-19 infection. 110 patients were evaluated retrospectively with histopathological confirmation of Mucormycosis. Surgical treatment was restricted to patients who tested Real Time Polymerase Chain Reaction (RT PCR) negative for COVID-19 except for three patients who were tested positive. Antifungal agents were given to patients following surgery.

RESULTS

A total of 110 patients with a mean age of 48.42 years were included. The most common risk factor was diabetes mellitus (88.2%). Sino-nasal, orbital, palatal and intracranial involvement were 57.9%, 48.5%, 12.7% and 5.6% respectively. Histopathological confirmation revealed mucormycosis. The most common reported symptoms were periorbital oedema (20.5%), headache (20.3%), gingival swelling (18.5%) facial pain (18.4%) and facial swelling (18.2%). All the patients were treated with surgical debridement and antifungal medications. The overall survival rate was 95.32%.

CONCLUSION

Acute Invasive Fungal Rhinosinusitis is a life-threatening opportunistic infection. Patients with moderate to severe COVID-19 infection are more susceptible to it. Uncontrolled diabetes mellitus and intake of corticosteroids increase the risk of developing Acute Invasive Fungal Rhinosinusitis. Early diagnosis and timely management can improve survival rates of the patients.

Outcomes of a Modified Treatment Ladder Algorithm Using Retrobulbar Amphotericin B for Invasive Fungal Rhino-Orbital Sinusitis

PURPOSE

To assess whether a modified treatment ladder algorithm incorporating transcutaneous retrobulbar amphotericin B (TRAMB) for invasive fungal rhino-orbital sinusitis can reduce the risk of exenteration without compromising survival.

DESIGN

Retrospective, comparative clinical study with historical control subjects.

METHODS

Fifty consecutive patients with biopsy-proven invasive fungal sinusitis and radiographic evidence of orbital involvement were evaluated at a single tertiary institution from 1999-2020. TRAMB was incorporated as part of the treatment algorithm in 2015. Demographics, underlying immune derangement, infective organism, ophthalmic examination, surgical care, and survival were compared in a quasiexperimental pre-post format, dividing patients into a pre-2015 group and a post-2015 group. Risk of exenteration and mortality were the primary outcomes.

RESULTS

Baseline characteristics did not differ significantly between the 2 groups. Nearly all patients underwent a surgical intervention, most commonly functional endoscopic sinus surgery with debridement. TRAMB was administered to 72.7% of the post-2015 group. Exenteration was more common in the pre-2015 group (36.4% vs 9.1% [95% confidence interval {CI} 5.2-48.8]; P = .014), while mortality was similar (40.0% vs 36.7% [95% CI -22.1 to 29.3]; P = .816). After adjusting for potential confounders, patients treated after 2015 were found to have lower risk of exenteration (relative risk 0.28 [95% CI 0.08-0.99]; P = .049) and similar risk of mortality (relative risk 1.04 [95% CI 0.50-2.16]; P = .919).

CONCLUSION

Compared with historical control subjects, patients with invasive fungal rhino-orbital sinusitis who were treated with a modified treatment ladder algorithm incorporating TRAMB had a lower risk of disfiguring exenteration without an apparent increase in the risk of mortality.

CT imaging features in acute invasive fungal rhinosinusitis- recalling the oblivion in the COVID era

Objective

Methods

Results

Conclusion

Surgical & medical management of ROCM (Rhino-orbito-cerebral mucormycosis) epidemic in COVID-19 era and its outcomes - a tertiary care center experience

Objective

To evaluate the outcome of patients with ROCM (Rhino-orbito-cerebral mucormycosis) following their medical and surgical management.

Materials and methods

It is a prognostic study based in a tertiary care center in North-Western India. Patients who developed ROCM post COVID-19 infection from 1st September 2020 to 30th June 2021 were included in this study. Surgical debridement and administration of antifungal therapy was done for the post-COVID-19 ROCM patients. Disease progression and survival was studied up to 5 months of follow-up in the second wave.

Results

A total of 145 ROCM patients were included. The mean age at presentation, male: female ratio was 48.2 years and 2:1 respectively. As per our proposed new staging system and treatment strategy, the majority of patients belonged to stage II (31.72%) and stage III (31.03%). On a follow-up period of 5 months, 26 (18%) patients have lost their life and rest of the patients are on strict follow-up.

Conclusion

ROCM is an extremely aggressive fungal infection which rapidly became an epidemic following the COVID-19 pandemic. The diverse and unique presentation led us to evolve a new strategy to classify and manage these patients.

Emergence of Invasive Fungal Rhinosinusitis in Recently Recovered COVID-19 Patients

OBJECTIVE

The risk of invasive fungal rhinosinusitis is increased in Coronavirus disease 2019 (COVID-19) because of its direct impact in altering innate immunity and is further exacerbated by widespread use of steroids/antibiotics/monoclonal antibodies. The study aims to describe this recently increased clinical entity in association with COVID-19.

METHOD

A prospective, longitudinal study including patients diagnosed with acute invasive fungal rhinosinusitis (AIFRS) who recently recovered from COVID-19 infection or after an asymptomatic carrier state. A single-center, descriptive study investigating demographic details, clinical presentation, radio-pathological aspects, and advocated management.

RESULT

A total of 21 patients were included with a mean age of 49.62 years (SD: 14.24). Diabetes mellitus (DM) was the most common underlying disorder (90.48%), and 63.16% of all patients with DM had a recent onset DM, either diagnosed during or after COVID-19 infection. Nineteen patients (90.48%) had recently recovered from active COVID-19 infection, and all had a history of prior steroid treatment (oral/parenteral). Remaining 2 patients were asymptomatic COVID-19 carriers. Surprisingly, 2 patients had no underlying disorder, and 5 (23.81%) recently received the Covishield vaccine. Fungal analysis exhibited Mucor (95.24%) and Aspergillus species (14.29%). Most common sign/symptom was headache and facial/periorbital pain (85.71%), followed by facial/periorbital swelling (61.90%). Disease involvement: sinonasal (100%), orbital (47.62%), pterygopalatine fossa (28.58%), infratemporal fossa (14.29%), intracranial (23.81%), and skin (9.52%). Exclusive endoscopic debridement and combined approach were utilized in 61.90% and 38.10%, respectively. Both liposomal amphotericin B and posaconazole were given in all patients except one.

CONCLUSION

A high suspicion of AIFRS should be kept in patients with recent COVID-19 infection who received steroids and presenting with headache, facial pain, and/or facial swelling. Asymptomatic COVID-19 carriers and COVID-19 vaccinated candidates are also observed to develop AIFRS, although the exact immuno-pathogenesis is still unknown. Prompt diagnosis and early management are vital for a favorable outcome.

Accuracy of Intraoperative Frozen Section in Detection of Acute Invasive Fungal Rhinosinusitis

CONTEXT.—

Acute invasive fungal rhinosinusitis (AIFRS) is an aggressive form of fungal sinusitis, which remains a significant cause of morbidity and mortality. Early diagnosis and intervention are keys to improving patient outcomes. Intraoperative consultation has shown promise in facilitating early surgical intervention, but the accuracy of frozen section has not been clarified in this setting.

OBJECTIVES.—

To assess the accuracy of frozen-section diagnosis in patients with clinically suspected AIFRS.

DESIGN.—

All cases of clinically suspected AIFRS during a 10-year period (2009-2019) were retrospectively reviewed. The frozen-section results were compared with the final permanent sections as well as the tissue fungal culture results, following which the accuracy of frozen section was determined.

RESULTS.—

Forty-eight patients with 133 frozen-section evaluations for AIFRS were included in the study. Thirty of 48 patients and 61 of 133 specimens were positive for AIFRS on final pathology. Of 30 positive patients, 27 (90%) had at least 1 specimen diagnosed as positive during intraoperative consultation; among the 61 positive specimens, 54 (88.5%) were diagnosed as positive during intraoperative consultation. Of 72 negative specimens, all were interpreted as negative on frozen section. Thus, frozen sections had a sensitivity of 88.5% (95% CI, 0.78-0.97), specificity of 100% (95% CI, 0.94-1), positive predictive value of 100% (95% CI, 0.92-1), and negative predictive value of 90.6% (95% CI, 0.82-0.97).

CONCLUSIONS.—

This study represents the largest series assessing the diagnostic accuracy of frozen section analysis in AIFRS. These findings are useful in frozen section-informed intraoperative decision making.

Acute invasive fungal rhinosinusitis: Molecular identification and update in management of frozen section biopsy

The clinical diagnosis of Acute Invasive Fungal Rhinosinusitis (AIFRS) is technically difficult because it presents with non-exclusive and nonspecific clinical symptoms. Laboratory confirmation (usually via histopathologic techniques such as formalin-fixed paraffin-embedded (FFPE)) is necessary but it is time-consuming, despite the urgent need for timely diagnosis of AIFRS for effective management. This study aimed to investigate the sensitivity and specificity of the GMS frozen-section biopsy in the diagnosis of AIFRS and compare the same with that of different tissue staining methods to provide valid decision-grounds that may guide clinicians in prompt diagnosis of acute fungal invasive rhinosinusitis. A cross-sectional study was conducted in the Medical Mycology Laboratory, Faculty of Medicine, Iran University of Medical Sciences between 2018 and 2020 on 200 patients with suspected AIFRS referred to Baqiyatallah and Imam Khomeini Hospital, Tehran. All patients were subjected to diagnostic nasal endoscopy and computed tomography (CT) scan of paranasal sinuses. Magnetic resonance imaging (MRI) was done in cases of suspected intracranial extension. After screening by routine mycological examination, the diagnosis was confirmed using complementary molecular methods. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the frozen-section biopsy were also compared with FFPE. Of the 200 suspect patients, 47 cases (23.5%) met the criteria for AIFRS. Species of the genus Aspergillus were the predominant 27 (57.4%) followed by Mucorales species 10 (21.3%), and Fusarium spp 3 (6.4%). Also, 3 cases (6.4%) of co-infection due to Aspergillus/Rhizopus were reported. The accuracy, sensitivity, specificity, PPV, and NPV of frozen section assessments were 99.5%, 97.9%, 100%, 100% and 99.3%, respectively. For GMS frozen-section alone, sensitivity, specificity, NPV, and PPV was 100%. Overall, the calculated accuracy of FFPE was 98.5%, sensitivity was 94%, specificity was 100%, PPV was 100%, and NPV was 98.1%. Examination of the frozen-section biopsy is a highly predictive tool for a rapid and effective diagnosis of patients with suspected AIFRS. We observed that GMS frozen-section is a fast and reliable exam to confirm the diagnosis of fungal invasion, with good accuracy, sensitivity, and specificity compared to the gold-standard FFPE biopsy.

Acute Invasive Fungal Rhinosinusitis-Related Orbital Infection: A Single Medical Center Experience

Backgrounds

Acute invasive fungal rhinosinusitis (AIFRS) is a hazardous infectious disease with rapid progression and high mortality and morbidities. Further orbital involvement is commonly seen. This study aims to analyze risk factors, clinical characteristics, and outcomes between patients with or without orbital involvement.

Methods

A retrospective review was performed in a single tertiary medical center over a span of 13 years (2005–2018). A total of 21 patients with diagnosis of AIFRS were enrolled. We reviewed the patients' basic characteristics, comorbidities, clinical presentations, image study findings, culture pathogens, and treatment outcomes and analyzed the differences between orbital-involved and orbital sparing disease.

Results

The most common comorbidities in AIFRS were diabetes mellitus (DM) and hematological malignancy. Nine the 21 AIFRS patients had orbital-involved disease. Patients with orbital involvement had a higher prevalence of DM (p < 0.05). Image studies revealed significant infection of the ethmoid sinus, sphenoid sinus, and frontal sinus in the group with orbital complication (p < 0.05). Mucor, Rhizopus, and Aspergillus were cultured in both groups. Five patients in the orbital involvement group expired, with all of them having an initial presentation of conscious disturbance (p < 0.01). Rhino-orbital-cerebral fungal infection was noticed in 3 of the 5 expired patients.

Conclusion

In AIFRS patients, DM other than hematological malignancy was the main risk factor for orbital-involved disease. Patients with ethmoid, sphenoid, or frontal sinusitis had a higher possibility of orbital complication. Poor consciousness at initial presentation revealed highest possibility of rhino-orbital-cerebral fungal infection and led to death.

Clinical and surgical factors affecting the prognosis and survival rates in patients with mucormycosis

PURPOSE

To investigate the factors affecting disease specific mortality (DSM) in patients with mucormycosis.

METHODS

This retrospective study included 24 patients diagnosed with mucormycosis and who had undergone surgical and medical treatment between 2010 and 2020. There were 14 male and 10 female patients whose mean age was 53.70 ± 16.87 years, range 18-83. We reviewed the factors affecting DSM, including the extent of disease (paranasal sinus, palatal, orbital or intracranial involvement) and blood parameters (BP) that are serum glucose level (SGL), white blood cell, neutrophil, lymphocyte counts, C-reactive protein and hemoglobulin levels. Also, the effect of SGL in diabetes mellitus and BP in hematological malignancies on DSM was additionally evaluated.

RESULTS

Orbital (p = 0.001) and intracranial (p < 0.01) involvement had statistically significant effect on DSM but not the palatal involvement. When Cox regression analysis was employed to analyze the effect of multiple independent factors on DSM, only the extent of disease (p = 0.023) had statistically significant effect. Receiver operating characteristic analysis of SGL for diabetic patients demonstrated that the area under the curve was 0.917 (p = 0.016). A cut-off SGL of 360 mg/dl revealed an 83.3% sensitivity and 83.3% specificity for mortality outcome for diabetic patients having mucormycosis.

CONCLUSION

Orbital or cerebral involvement is related to a poor prognosis, so early endoscopic nasal examination, diagnosis and treatment are of vital importance for DSM in mucormycosis. Serum glucose level over 360 mg/dl in uncontrolled diabetic patients with fever, ophthalmological findings and facial hypoesthesia should necessitate a consultation to an otolaryngologist and an endoscopic careful nasal examination.

Invasive Fungal Sinusitis in Post COVID-19 Patients: A New Clinical Entity

Objectives

Occurrence of invasive fungal respiratory superinfections in patients with COVID‐19 has gained increasing attention in the latest studies. Yet, description of acute invasive fungal sinusitis with its management in those patients is still scarce. This study aims to describe this recently increasing clinical entity in relation to COVID‐19 patients.

Study Design

Longitudinal prospective study.

Methods

Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID‐19 infection. Antifungal agents given included amphotericin B, voriconazole, and/or posaconazole. Surgical treatment was restricted to patients with PCR negative results for COVID‐19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow‐up for survived patients was maintained regularly for the first postoperative month.

Results

A total of 36 patients with a mean age of 52.92 ± 11.30 years old were included. Most common associated disease was diabetes mellitus (27.8%). Mycological analysis revealed infection with Mucor and Aspergillus species in 77.8% and 30.6% of patients, respectively. Sino‐nasal, orbital, cerebral, and palatine involvement was found in 100%, 80.6%, 27.8%, and 33.3% of patients, respectively. The most common reported symptoms and signs are facial pain (75%), facial numbness (66.7%), ophthalmoplegia, and visual loss (63.9%). All patients were treated simultaneously by surgical debridement with antifungal medications except for two patients with PCR‐positive swab for COVID‐19. These two patients received antifungal therapy alone. Overall survival rate was 63.89% (23/36).

Conclusion

Clinical suspicion of acute invasive fungal sinusitis among COVID‐19 patients and early management with antifungal therapy and surgical debridement is essential for better outcomes and higher survival.

Level of Evidence

4 Laryngoscope, 131:2652–2658, 2021

A model for classification of invasive fungal rhinosinusitis by computed tomography

Our purpose was to classify acute invasive fungal rhinosinusitis (AIFR) caused by Mucor versus Aspergillus species by evaluating computed tomography radiological findings. Two blinded readers retrospectively graded radiological abnormalities of the craniofacial region observed on craniofacial CT examinations obtained during initial evaluation of 38 patients with eventually pathology-proven AIFR (13:25, Mucor:Aspergillus). Binomial logistic regression was used to analyze correlation between variables and type of fungi. Score-based models were implemented for analyzing differences in laterality of findings, including the 'unilateral presence' and 'bilateral mean' models. Binary logistic regression was used, with Score as the only predictor and Group (Mucor vs Aspergillus) as the only outcome. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were determined for the evaluated models. Given the low predictive value of any single evaluated anatomical site, a 'bilateral mean' score-based model including the nasal cavity, maxillary sinuses, ethmoid air cells, sphenoid sinus and frontal sinuses yielded the highest prediction accuracy, with Mucor induced AIFR correlating with higher prevalence of bilateral findings. The odds ratio for the model while integrating the above anatomical sites was 12.3 (p < 0.001). PPV, NPV, sensitivity, specificity and accuracy were 0.85, 0.82, 0.92, 0.69 and 0.84 respectively. The abnormal radiological findings on craniofacial CT scans of Mucor and Aspergillus induced AIFR could be differentiated based on laterality, with Mucor induced AIFR associated with higher prevalence of bilateral findings.

Deadly Sphenoid Fungus-Isolated Sphenoid Invasive Fungal Rhinosinusitis: A Case Report

INTRODUCTION

Acute invasive fungal rhinosinusitis (AIFRS) is a potentially fatal infection, usually affecting immunocompromised patients. Isolated sphenoid sinus involvement is rare and has been reported in only a few cases. We discuss the clinical characteristics, histopathologic features, and differential diagnosis of AIFRS of the sphenoid sinus.

CASE PRESENTATION

A 57-year-old man with a history of refractory non-Hodgkin lymphoma and neutropenia presented with a 1-week duration of left-sided headache and ipsilateral cheek paresthesia. Nasal endoscopy showed mucoid drainage from the sphenoethmoidal recess. Magnetic resonance imaging demonstrated left sphenoid mucosal thickening and enhancement along the adjacent skull base. The patient underwent endoscopic sinus surgery with extended sphenoidotomy and débridement. The lateral wall and recess of the left sphenoid sinus demonstrated pale mucosa and fungal debris. Pathologic analysis demonstrated necrotic tissue and fungal hyphae with angioinvasion. Microbiology studies isolated Aspergillus fumigatus. The right maxillary sinus contained a synchronous fungal ball, which was removed during surgery; there was no evidence of tissue necrosis or invasive fungus in the maxillary sinus. He was treated with long-term voriconazole therapy, and 6-month follow-up showed disease resolution.

DISCUSSION

AIFRS should be considered in the differential diagnosis of immunocompromised patients with nonspecific sinonasal symptoms. Usually, AIFRS is diffuse with multiple sinus involvement; however, isolated sphenoid AIFRS can occur. This is one of the few cases of AIFRS demonstrating isolated sphenoid involvement and is thought to be the first case showing a synchronous noninvasive fungal ball of another sinus cavity. Prompt recognition and surgical treatment may be curative and lifesaving.

[Histopathological Diagnosis of Fungal Sinusitis and Variety of its Etiologic Fungus]

 Fungal sinusitis is divided into two categories depending on mucosal invasion by fungus, i.e., invasive and noninvasive. Invasive fungal sinusitis is further divided into acute and chronic disease based on time course. Noninvasive fungal sinusitis includes chronic noninvasive sinusitis (fungal ball type) and allergic fungal sinusitis. Chronic noninvasive sinusitis is the most predominant fungal sinusitis in Japan, followed by allergic fungal sinusitis. Invasive fungal sinusitis is rare. Hyphal tissue invasion is seen in invasive fungal sinusitis. Acute invasive fungal sinusitis demonstrates hyphal vascular invasion while chronic invasive fungal sinusitis usually does not. Fungal tissue invasion is never found in noninvasive sinusitis. A fungal ball may exist adjacent to sinus mucosa, but its hyphae never invade the mucosa. Fungal balls sometimes contain conidial heads and calcium oxalate, which aid in identifying the fungus in the tissue. Allergic fungal sinusitis is characterized by allergic mucin that is admixed with numerous eosinophils and sparsely scattered fungal elements. Histopathology is important in classifying fungal sinusitis, especially in confirming tissue invasion by the fungus.

Presentation of Lesions of Nose and Paranasal Sinuses at a Tertiary Care Center in Central India

A variety of non-neoplastic and neoplastic conditions involve the nasal cavity, paranasal sinus and are fairly common presentation encountered in clinical practice. Sinonasal lesions are a common finding in all age groups. The lesion of nose and paranasal sinuses are very deceptive so, the presenting features, clinical examination, nasal endoscopy, radiodiagnosis and histopathology are employed conjointly to reach a diagnosis. This cross sectional study was conducted between November 2014 and September 2016. 150 patients with nasal or paranasal sinus lesions attending ENT OPD were included. Among 150 patients there was a male predominance in all lesion except malignant lesions and most of the patients 72 (48%) were in the age group 11- 30 years. Mean age of presentation for benign lesions was 33.64 years and of malignant lesions was 49.14 years. The study showed that 96 (64%) of the nose and PNS lesions were of inflammatory nature followed by 22 (15%) benign, 18 (12%) granulomatous and 14 (9%) malignant, Inflammatory polyp being the most common diagnosis. Haemangioma was the most common benign neoplastic lesion whereas in granulomatous lesions most common diagnosis was tuberculosis. The maximum lesions 74 (49%) were in maxillary antrum. The most common clinical presentation was nasal obstruction, with unilateral nasal obstruction seen in 84 (56%) cases and bilateral nasal obstruction in 50 (33.3%) cases. Angiofibroma 6 (4%) was exclusively seen in adolescent males. Olfactory neuroblastoma 4 (2.6%) was diagnosed in females with mean age of presentation of 30 years. Sinonasal lesions display a complex and interesting spectrum of clinical, radiological and histopathologic features. The non-neoplastic lesions are numerous, the morphologic variants of neoplasms are many and most of them present as polypoid masses which are impossible to distinguish clinically. Hence a proper workup including histopathological and radiological categorization is essential in the management of these lesions.

Invasive fungal sinusitis: treatment of the orbit

PURPOSE OF REVIEW

To summarize diagnostic techniques for invasive fungal rhinosinusitis and provide a review of treatment options once disease has spread to the orbit.

RECENT FINDINGS

Improved imaging criteria, polymerase chain reaction and other serologic tests show promise in advancing our ability to accurately diagnose invasive fungal disease. Currently, there exists three treatment options for infected orbital tissue: exenteration, conservative debridement and transcutaneous retrobulbar injection of amphotericin B. Exenteration, the most frequently reported intervention, has not been proven to enhance survival. Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are increasingly considered reasonable first-line options.

SUMMARY

Although investigative tools are improving, invasive fungal rhinosinusitis can still pose a diagnostic challenge. No one treatment option for the orbit has been proven superior to another. Therefore, it is justified to initiate therapy by prioritizing less morbid procedures. If deterioration is continually noted, more invasive interventions can then be employed. The treatment algorithm established at our institution is provided.

Acute Rhinosinusitis in Immunosuppressed Children: Diagnostic and Therapeutic Management

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.

Inflammatory and Infectious Lesions of the Sinonasal Tract

The sinonasal tract is frequently affected by nonneoplastic inflammatory diseases. Inflammatory lesions of the sinonasal tract can be divided into 3 main categories: chronic rhinosinusitis, which encompasses a heterogeneous group of entities, all of which result in mucosal inflammation with or without polyps-eosinophils; infectious diseases; and autoimmune diseases and vasculitides, which can result in midline necrosis and facial deformities. This article reviews the common inflammatory lesions of the sinonasal tract with emphasis on infectious diseases, vasculitis, iatrogenic, and diseases of unknown cause. Many of these lesions can result in midline destruction and result in facial deformity.

Acute Invasive Fungal Rhinosinusitis in Children With Hematologic Malignancies: Outcome of Surgical Treatment

The incidence of acute invasive fungal rhinosinusitis (AIFR) is rising due to more aggressive chemotherapy and longer survival of immunosuppressed patients. Early diagnosis and appropriate but nonmutilating surgical treatment are particularly problematic in the pediatric population. This study aimed to evaluate the outcome of surgery for pediatric AIFR. Medical records of children surgically treated for AIFR between 1998 and 2014 were reviewed. Diagnosis was based on both histopathological and microbiological confirmation. Surgery was performed with curative intent and repeated for any resectable extension. The children underwent endoscopy and magnetic resonance imaging every 2 and 6 months, respectively, during the first postoperative year. Thirteen patients (2-18 years old) met the EORTC/MSG criteria for proven invasive fungal sinusitis; fungal invasion was diagnosed by preoperative biopsy and confirmed in the surgical specimen. All patients underwent an average of two endoscopic procedures (range 1-3), and four of them also underwent an open surgery. The local control rate was at least 79%. There was no facial disfiguration during follow-up (average 41 months). Although AIFR is still associated with high mortality, aggressive medical and surgical treatment provides local control in most cases. Fair outcome should encourage a maximal joint effort of pediatric hemato-oncologists and otorhinolaryngologists in the management of AIFR.

Acute invasive fungal rhinosinusitis: Survival analysis and the prognostic indicators

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is a highly mortal, progressive fungal infection of the paranasal sinuses and surrounding structures that is almost always seen in patients who are immunocompromised. Despite the use of newer antifungal treatments and early diagnosis, the prognosis of AIFR does not improve significantly. Due to the higher incidence of patients who are immunocompromised and have more complex disease, AIFR is a growing medical issue in tertiary medical centers.

OBJECTIVE

The aim of this study was to present the outcomes and analyze the prognostic indicators of patients with AIFR who underwent surgery.

METHODS

Between October 2009 and November 2014, 37 patients who underwent surgery for AIFR at a tertiary care university hospital were included in the study. Overall survival and disease-specific mortality and survival rates were calculated to estimate survival function. The impact of age, sex, underlying disease, extent of AIFR, applied medical treatment, and causative species (mucormycosis, aspergillosis) were also taken into consideration. Also, the effect of a variety of laboratory parameters, such as hemoglobin, leukocyte, neutrophil, lymphocyte, platelet, and C-reactive protein (CRP) levels, to survival were evaluated.

RESULTS

The median follow-up time was 58 days (interquartile range = 304). Overall and disease-specific mortality rates were 64.9 and 51.4%, respectively. Fever was the most common symptom (86.5%), along with nasal obstruction and/or fullness (48.6%) and epistaxis (48.6%). Age and sex did not have a significant impact on survival (p > 0.05). Palate involvement was significantly associated with mortality (p < 0.05). According to the results of Cox, regression analysis for disease-specific mortality rate, leukocyte and neutrophil counts as well as CRP levels had a significant effect on survival function (p < 0.05).

CONCLUSIONS

Palatal involvement was associated with a higher mortality in our study. Also, leukocyte counts, neutrophile counts, and CRP values had a significant impact on survival function. The reversal of the underlying disease and immunosuppression is as important as the medical and surgical treatment.

Invasive Fungal Sinusitis by Lasiodiplodia theobromae in an Patient with Aplastic Anemia: An Extremely Rare Case Report and Literature Review

Human Lasiodiplodia theobromae infection has not been reported frequently. We report the first case of invasive L. theobromae nasal and neck infection. A 66-year-old male visited our hospital with anemia and general weakness. He showed pancytopenia, and his bone marrow examination revealed markedly decreased hematopoietic cells. The patient was presumed to have iatrogenic aplastic anemia due to mushroom toxicity. He began treatment for multiple organ infections with broad-spectrum antibiotics and antifungal agents. During hospitalization, he complained of nasal obstruction and left neck lymph node enlargement. A mass-like lesion was observed, and a nasal mass biopsy was performed. The mass was identified as a fungal ball. He underwent surgical excision for the nasal mass and the neck lymph node. The pathologic examination indicated an invasive fungal infection, and the lymph node revealed chronic granulomatous inflammation with fungal infection. 18s rRNA sequencing revealed that the sequence shared 99 % identity with L. theobromae. The nasal mass fungus was identified by internal transcribed spacer region sequencing from pathologic paraffin sections. The obtained sequence corresponded to Lasiodiplodia or Macrophoma. The sequence corresponded to the neck discharge sequence results. Hence, the patient was diagnosed with invasive fungal sinusitis with neck lymph node involvement caused by L. theobromae. To our knowledge, this is the first report of L. theobromae infection in Korea and the first report of invasive L. theobromae fungal sinusitis in the literature. We should include more precise evaluations of additional novel fungal species as possible candidates.

An evaluation of invasive fungal sinusitis outcomes with subsite analysis and use of frozen section analysis

BACKGROUND

Invasive fungal sinusitis (IFS) is an aggressive mycosis of the nasal cavity with frequent extension to adjacent structures. Occurring more commonly in immunocompromised individuals, prognosis is typically poor despite aggressive treatment. This study aims to examine postoperative outcomes and survival of a cohort of fungal sinusitis patients at an academic center, as well as identify causes of death in IFS patients.

METHODS

This study was a retrospective chart review of patient charts and departmental records, yielding patient demographics, medical and surgical treatments, pathology records, and outcomes data.

RESULTS

Twenty-seven patients were identified from departmental records between 1998 and 2014. Twenty-one patients presented with Mucor infections, whereas the remaining 6 patients had Aspergillus. All patients were immunocompromised: diabetes (n = 14) and hematologic malignancy (n = 13). Three patients had multiple causes of immunosuppression. Most commonly involved subsites were the maxillary, ethmoid, and sphenoid sinuses. Nasal septum involvement was independently associated with mortality (p < 0.01). Overall mortality was 57.7% within 1 year, although 66.7% of fatalities occurred within 1 month of diagnosis.

CONCLUSION

Overall survival for IFS remains poor. Widespread disease and nasal septum involvement were associated with a negative clinical course. Early identification and aggressive surgical and antifungal therapy is warranted. Even despite intense therapy, comorbid conditions and drug toxicity increase mortality and complicate the clinical course.

Differential Diagnosis of Necrotizing Sinonasal Lesions

CONTEXT

A number of entities may result in necrosis in the sinonasal tract and lead to significant morbidity and mortality. These include infections, necrotizing vasculitis, neoplastic processes, and drug dependency. This review will concentrate on the differential diagnosis of sinonasal necrotizing lesions.

OBJECTIVE

To review the differential diagnoses of necrotizing destructive lesions of the sinonasal tract.

DATA SOURCES

The current literature was reviewed to provide updated information regarding the differential diagnosis of sinonasal necrotizing lesions, including infectious disease processes; antineutrophilic cytoplasmic antibody-associated vasculitides; neoplastic processes, particularly natural killer/T-cell lymphomas; and drug abuse.

CONCLUSIONS

The differential diagnosis of necrotizing sinonasal lesions is broad, with often overlapping diagnostic features that lead to diagnostic challenges. Ancillary tests such as special stains and immunohistochemical studies can offer significant assistance.

Pathology of Fungal Rhinosinusitis: A Review

Fungal rhinosinusitis (FRS) comprises a spectrum of disease processes that vary in clinical presentation, histologic appearances, and biological significance. FRS can be acute or chronic and is most commonly classified as non-invasive or invasive based on whether fungi have invaded into tissue. This manuscript will review the pathologic classification of FRS.

Invasive fungal rhinosinusitis in adult patients: Our experience in diagnosis and management

BACKGROUND

This paper describes our experience in the management of acute and chronic invasive fungal rhinosinusitis (IFRS) in adults.

METHODS

Medical files of all patients aged >18 years treated in our institutions for IFRS from 2002 to 2013 were retrospectively reviewed.

RESULTS

A total of 18 cases (10 acute and 8 chronic) were recorded. In acute form, haematological malignancies represented the principal comorbidity (100%), while in chronic form this was diabetes mellitus (87.5%). All patients received systemic antifungal agents. Endoscopic sinus surgery was performed in 16/18 patients (88.9%). Among patients with an acute IFRS, 4/10 died of fungal infection (40%), on the other side 2/8 patients with chronic IFRS died of the evolution of the mycosis (25%).

CONCLUSIONS

Acute and chronic IFRS are different entities: in acute form, prognosis is poor, so therapy should be promptly performed, although host immune status and evolution of the haematological disease are key factors for the outcome. In chronic form, a wide surgical excision of the disease is recommended in order to obtain a complete removal of fungal infection. In both forms, early clinical findings are non-specific and ambiguous, so diagnosis depends on a high index of suspicion, taking into account predisposing factors.

Invasive mould sinusitis in patients with haematological malignancies: a 10 year single-centre study

OBJECTIVES

Invasive mould sinusitis (IMS) is a severe infection in patients with haematological malignancies. Because of a paucity of contemporaneous data about IMS, we sought to evaluate clinical aspects and outcome of IMS in these patients.

METHODS

The records of adult haematological malignancy patients with proven or probable IMS over a 10 year period were reviewed retrospectively.

RESULTS

We identified 44 patients with IMS. Mucorales were isolated in 13 (35.1%) patients and Fusarium and Aspergillus were isolated in 9 (24.3%) patients each. Patients with IMS owing to Mucorales were more likely to have a history of diabetes mellitus (P = 0.003) and high-dose corticosteroid use (P = 0.03). Thirty-five (80%) patients received antifungal combinations and 36 (82%) underwent surgical debridement. The 12 week IMS-attributable mortality was 36.4% (16 patients). A relapsed and/or refractory haematological malignancy was an independent risk factor for 6 week IMS-attributable (P = 0.038), 12 week all-cause (P = 0.005) and 12 week IMS-attributable (P = 0.0015) mortality. Neutrophil count <100/µL and lymphocyte count <200/µL were associated with increased 12 week IMS-attributable and 6 week all-cause mortality, respectively (P = 0.044 and 0.013). IMS due to Aspergillus was an independent risk factor for both 12 week all-cause (P = 0.011) and IMS-attributable (P = 0.026) mortality. Initial antifungal therapy with a triazole-containing regimen was associated with decreased 6 week all-cause (P = 0.032) and IMS-attributable (P = 0.038) mortality. Surgery was not an independent factor for improved outcome.

CONCLUSIONS

Despite combined medical and surgical therapy, IMS had high mortality. Mortality risk factors were relapsed and/or refractory malignancy, cytopenia and Aspergillus infection in this study.

Prognostic Factors for Survival in Patients with Acute Invasive Fungal Rhinosinusitis

Background

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. There are few reports that demonstrate an improvement in the overall prognosis. Furthermore, definite prognostic factors related to patient survival remain unclear.

Objective

The objective of this study was to evaluate the various clinical factors related to survival of patients with AIFR.

Methods

This is a retrospective case series with patients treated for AIFR between 1997 and 2013. A total of 45 patients with AIFR were enrolled for analysis. We evaluated demographics, clinical characteristics, and disease course.

Results

Mean age of patients was 59.6 years. AIFR developed most commonly in patients with immunocompromised host, such as diabetes (n = 23) or hematologic malignancy (n = 17). There were two main genera of fungus, Aspergillus (n = 30) and Mucor (n = 14). Headache, cranial neuropathy, visual loss, and orbital pain were the most common presenting symptoms. Overall survival was 53%. Underlying hematologic malignancy and diabetes were significantly associated with overall survival, and accompanying severe neutropenia and elevated C-reactive protein (CRP) were also related to poor prognosis. Initial presentation with facial swelling, involvement of nasal septum, or shorter symptom duration was also associated with survival reduction. Multivariate analysis revealed that CRP more than 5.50 mg/dL (Hazard ratio [HR], 9.04; p = 003) was an independent prognostic factor in patients with AIFR.

Conclusions

Overall survival rate remained approximately 50% in patients with AIFR. The prognosis of AIFR is significantly influenced by underlying diseases, accompanying neutropenia, CRP levels, symptom duration, involvement of septum, and the presence of facial swelling. Elevation of CRP, in particular, was an independent predictor of poor outcomes and should be monitored appropriately.

A novel fungus concentration-dependent rat model for acute invasive fungal rhinosinusitis: an experimental study

Background

Acute invasive fungal rhinosinusitis is a lethal infectious process afflicting immunocompromised individuals. Knowledge about this disease is still limited due to the scarcity of animal models designed to study the pathogenesis of this infection. Mast cells are tissue-resident immune cells that participate in a variety of allergic and inflammatory conditions. Limited attention has been given to the role of mast cells in acute invasive fungal rhinosinusitis. Therefore, the objectives of this study were to create a rat model of acute invasive fungal rhinosinusitis based on analyzing the impact of different fungal concentrations on establishing infection, and to observe the changes of mast cells in rats with this disease.

Methods

Sprague–Dawley rats were divided randomly into four groups, three of which were experimental and received different concentrations of Aspergillus fumigatus inoculations, and one was a control group (D). The inoculated Aspergillus fumigatus concentrations were 5 × 10⁷ conidia/ml in group A, 10⁷ conidia/ml in group B, and 10⁶ conidia/ml in group C. Before fungal inoculation, rats were immunosuppressed using cyclophosphamide and cortisone acetate, and had Merocel sponges inserted into the right nares. Hematology and histopathology investigations were then performed.

Results

An acute invasive fungal rhinosinusitis rat model was established successfully with an incidence rate of 90% in group A, 50% in group B and 10% in group C. Aspergillus fumigatus invasion was observed in 20% of the lungs in group A, but was not seen in the remaining groups. In addition, no fungi invaded the orbital tissue, brains, livers, spleens or kidneys of any rat. Compared with the control set, the total number of mast cells in the experimental groups was not significantly increased, but mast cell degranulation, on the other hand, was only found in infected nasal cavities.

Conclusions

This investigation illustrates that various fungal concentrations have different effects on the incidence of acute invasive fungal rhinosinusitis, and it also demonstrates the feasibility of using this model to study the process of fungal rhinosinusoidal invasion. In addition, the results suggest that mast cells may play a role in the protection of sinuses against acute Aspergillus fumigatus infection and in the clearance of established hyphal masses.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0713-y) contains supplementary material, which is available to authorized users.

The role of surgical debridement in different clinical manifestations of invasive aspergillosis

Invasive aspergillosis (IA) has a wide spectrum of clinical presentations and is associated with high mortality rates. Early initiation of systemic antimould therapy remains the most important measure to reduce mortality. Surgical debridement is an important additional therapeutic option mainly in cases of extrapulmonary IA. The main intention for surgical intervention in IA is to obtain material for diagnosis and antifungal susceptibility testing. There are, however, also therapeutic implications for surgical interventions in rare manifestation of IA such as endocarditis or mycotic aneurysm. Here, we will review the role of surgical interventions in the treatment of different clinical manifestations of IA.

The role of fungi in diseases of the nose and sinuses

BACKGROUND

Human exposure to fungal elements is inevitable, with normal respiration routinely depositing fungal hyphae within the nose and paranasal sinuses. Fungal species can cause sinonasal disease, with clinical outcomes ranging from mild symptoms to intracranial invasion and death. There has been much debate regarding the precise role fungal species play in sinonasal disease and optimal treatment strategies.

METHODS

A literature review of fungal diseases of the nose and sinuses was conducted.

RESULTS

Presentation, diagnosis, and current management strategies of each recognized form of fungal rhinosinusitis was reviewed.

CONCLUSION

Each form of fungal rhinosinusitis has a characteristic presentation and clinical course, with the immune status of the host playing a critical pathophysiological role. Accurate diagnosis and targeted treatment strategies are necessary to achieve optimal outcomes.

Invasive fungal rhinosinusitis: a 15-year experience with 29 patients

OBJECTIVES/HYPOTHESIS

Document a 15-year experience with 29 cases of acute invasive fungal rhinosinusitis (AIFR) and evaluate factors predictive of disease clearance and overall survival.

STUDY DESIGN

Case series with chart review.

METHODS

Patients were identified by review of department billing records between 1995 and 2010. Medical records were reviewed for patient demographics, disease characteristics, clinical course including surgical and medical therapy, treatment outcomes, and long-term survival.

RESULTS

Twenty-nine patients with AIFR were identified. Causes of immunosuppression included hematologic malignancy (n=16), diabetes (n=12), medication (n=10), and acquired immunodeficiency syndrome (n=1), with 10 patients having multiple causes of immunosuppression. Facial pain, swelling and orbital symptoms were the most common presenting symptoms. Fungal organisms included Mucor (n=18) and Aspergillus (n=10) species, with one patient infected with both. Disease-specific survival (DSS) from AIFR was 57%. Intracranial (P=.01) and ethmoid sinus (P=.05) involvement were significantly linked with short-term disease-related mortality. Overall survival (OS) at 6 months was 18%. For OS, intracranial involvement (hazard ratio [HR], 4.47; 95% confidence interval [CI], 1.51-13.22) and cranial neuropathy at presentation (HR, 3.2; 95% CI, 1.3-8.2) were significantly associated with shortened survival. Of the five patients surviving >6 months, two developed long-term major sinonasal complications.

CONCLUSIONS

DSS and OS remain low for patients with AIFR. Extensive surgical resection in patients with these poor prognostic signs should be considered carefully in light of their poor survival. Long-term survivors are at significant risk of sinonasal complications and should be followed closely.

Cervicofacial tissue infarction in patients with acute invasive fungal sinusitis: prevalence and characteristic MR imaging findings

INTRODUCTION

Tissue infarction is known as one of the characteristic features of invasive fungal sinusitis (IFS). The purpose of this study was to investigate the prevalence and characteristic MR imaging findings of cervicofacial tissue infarction (CFTI) associated with acute IFS.

METHODS

We retrospectively reviewed MR images in 23 patients with histologically or microbiologically proven acute IFS. CFTI was defined as an area of lack of enhancement in and around the sinonasal tract on contrast-enhanced T1-weighted images. We divided CFTI into two groups, i.e., intrasinonasal and extrasinonasal. Particular attention was paid to the location of extrasinonasal CFTI and the signal intensity of CFTI on T1- and T2-weighted images. The presence of bone destruction on CT scans was also recorded.

RESULTS

CFTI was found in 17 (74%) of 23 patients. All of these 17 patients had intrasinonasal CFTI, and 13 patients also had extrasinonasal CFTI. All 13 patients with extrasinonasal CFTI died of disease directly related to IFS. Various locations were involved in the 13 patients with extrasinonasal CFTI, including the orbit (n = 8), infratemporal fossa (n = 7), intracranial cavity (n = 3), and oral cavity and/or facial soft tissue (n = 4). Various signal intensities were noted at the area of CFTI on T1- and T2-weighted images. Bone destruction was found on CT scans in only 3 of 17 patients with CFTI.

CONCLUSION

CFTI with preservation of the bony wall of the involved sinonasal tract may be a characteristic MR imaging finding of acute IFS. The mortality is very high once the lesion extends beyond the sinonasal tract.

Survival outcomes in acute invasive fungal sinusitis: a systematic review and quantitative synthesis of published evidence

OBJECTIVES/HYPOTHESIS

Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. The current study systematically reviews and quantitatively synthesizes the published literature to characterize prognostic factors associated with survival.

STUDY DESIGN

Systematic review.

METHODS

Fifty-two studies comprising a total of 807 patients met inclusion criteria and were used for analysis of treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors.

RESULTS

All studies were classified as level 4 evidence, as per definitions provided by the Oxford Center for Evidence-Based Medicine. The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall survival rate was 49.7%. On univariate analysis, poor prognosis was associated with renal/liver failure, altered mental status, and intracranial extension. Patients who were diabetic, had surgery, or received liposomal amphotericin B had an improved chance of survival. On multivariate analysis, advanced age and intracranial involvement were identified as independent negative prognostic factors. Positive prognostic factors again included diabetes and surgical resection.

CONCLUSIONS

The overall mortality of patients with AIFS remains high, with only half of the patients surviving. Diabetic patients appear to have a better overall survival than patients with other comorbidities. Patients who have intracranial involvement, or who do not receive surgery as part of their therapy, have a poor prognosis.

LEVEL OF EVIDENCE

N/A.

Endonasal treatment of acute invasive fungal rhinosinusitis in immunocompromised pediatric hematology-oncology patients

OBJECTIVES

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive fungal infection in immunocompromised patients with high mortality rates. The aim of this study is to present our experiences on endonasal treatment in immunocompromised pediatric hematology-oncology patients with AIFR.

METHODS

Thirteen pediatric hematology-oncology patients treated for AIFR between March 2006 and December 2011 were analyzed retrospectively. We reviewed the following data for all patients: age, gender, predisposing disease, initial symptoms, pathological diagnosis, microbiological results, laboratory findings, surgical procedure, number of operations and treatment outcomes.

RESULTS

Nine of 13 patients with lesions confined to sinonasal cavity were operated with endoscopic approach. Open surgery was performed in four patients, three of them had palatal and buccal lesions and one had facial skin involvement. Endoscopic approach was also used for sinonasal lesions of these four patients. A total of 7 patients died: 4 patients with progression of the underlying disease, 2 patients with sepsis and 1 patient due to renal failure. Survival rate in surgically treated patients was found 46% (6/13 patients).

CONCLUSIONS

Endonasal endoscopic approach is both feasible and efficient technique, also enables excellent local control with less morbidity compared to open surgery. This approach is suitable for patients who are diagnosed in the early stages of AIFR and also presents a less traumatic option for patients with poor health status. Open surgical procedure should be preferred in patients with disease extending out of the sinonasal cavity.

Invasive fungal sinusitis in patients with hematological malignancy: 15 years experience in a single university hospital in Taiwan

Background

Risk factors and outcomes in hematological patients who acquire invasive fungal sinusitis (IFS) are infrequently reported in the modern medical era.

Method

A retrospective study of hospitalized patients with hematological disease was conducted at National Taiwan University Hospital between January 1995 and December 2009.

Results

Clinical characteristics and outcomes with their associated radiographic and microbiological findings were analyzed. Forty-six patients with IFS and 64 patients with chronic non-invasive sinusitis were enrolled as comparsion. IFS developed more commonly in patients with acute myeloid leukemia (AML) and with prolonged neutropenia (absolute neutrophil count less than 500/mm³ for more than 10 days) (p < 0.001). Aspergillus flavus was the most common pathogen isolated (44%). Serum Aspergillus galactomannan antigen was elevated in seven of eleven patients (64%) with IFS caused by aspergillosis but negative for all three patients with mucormycosis. Bony erosion and extra-sinus infiltration was found in 15 of 46 (33%) patients on imaging. Overall, 19 of 46 patients (41.3%) died within 6 weeks. Patients with disease subtype of AML (p = 0.044; Odds Ratio [OR], 5.84; 95% confidence interval [95% CI], 1.02-30.56) and refractory leukemia status (p = 0.05; OR, 4.27; 95% CI, 1.003-18.15) had worse prognosis. Multivariate analysis identified surgical debridement as an independent good prognostic factor (p = 0.047) in patients with IFS.

Conclusions

Patients of AML with prolonged neutropenia (> 10 days) had significantly higher risk of IFS. Early introduction of anti-fungal agent and aggressive surgical debridement potentially decrease morbidity and mortality in high risk patients with IFS.

In situ hybridization for specific fungal organisms in acute invasive fungal rhinosinusitis

Acute invasive fungal rhinosinusitis (AIFRS) most commonly occurs in immunosuppressed patients. The identification of fungal subtypes is important for management, and cultures can be negative. We studied 55 specimens from 23 patients with AIFRS (Rhizopus sp, 6; Aspergillus sp, 8; Fusarium sp, 1; Alternaria sp, 1; and culture negative, 7) using in situ hybridization (ISH) with biotin-labeled oligonucleotide probes targeting Aspergillus sp, Fusarium sp, Rhizopus sp, and a sequence identified in dematiaceous fungi. Ribosomal RNA preservation was established by using a pan-fungal probe. Nucleic acid preservation was seen in 18 patients (33 specimens [60%]). ISH using the specific fungal probes highlighted the respective fungal organisms in all culture-positive cases with adequate negative controls. Of the 7 culture-negative AIFRS cases, 4 had preserved fungal sequences. Of these cases, 2 additional cases of Aspergillus and 1 additional case of dematiaceous species were identified. In our study, 60% of AIFRS cases had fungal nucleic acid preservation. ISH can effectively identify fungi in AIFRS. ISH for specific fungal pathogens may aid in species identification in specimens with negative cultures.

Acute invasive fungal rhinosinusitis: Evaluation of 26 patients treated with endonasal or open surgical procedures

OBJECTIVE

Acute invasive fungal rhinosinusitis (AIFRS) is a serious disease with a high mortality and morbidity rate, which almost always affects immunocompromised patients and/or patients with diabetes mellitus. Our purpose was to present the diagnostic and therapeutic management and outcome of these patients.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

Twenty-six patients, who were operated on because of AIFRS between September 1999 and June 2009, were retrospectively evaluated in this study. Endoscopic surgery was used in 19 patients, and open surgical debridement was performed in seven patients.

RESULTS

Overall survival rate of the patients in the open surgery group (4 of 7; 57.1%) was similar to that of the endoscopically treated group (9 of 19; 47.3%). Thirteen patients (50%) died of complications related to the underlying disease (9 of 13; 69.2%) and AIFRS (4 of 13; 30.7%). AIFRS-specific survival rate is 76.5 percent; 90 percent (9 of 10) and 57.1 percent (4 of 7) for endoscopic and open surgery groups, respectively. Four patients who died had pathological diagnosis of mucormycosis ( P = 0.52).

CONCLUSION

AIFRS can be successfully treated with a combination of endonasal surgical debridement and antifungal medications. Endonasal approach is suitable for patients diagnosed in the early stages of the disease and provides a less traumatic option in those patients who already have a poor health status. Open surgery should be preferred in the presence of intraorbital extension, palatinal, and/or intracerebral involvement. Reversing the underlying disease process and immunosuppression is as important as the surgical and antifungal treatment.