Fungal sinusitis: histologic spectrum and correlation with culture

Eosinophilic mucus diseases

Eosinophilic inflammation is primarily characterized by type 2 immune responses against parasitic organisms. In the contemporary human being especially in developed countries, eosinophilic inflammation is strongly associated with allergic/sterile inflammation, and constitutes an undesired immune reaction. This situation is in stark contrast to neutrophilic inflammation, which is indispensable for the host defense against bacterial infections. Among eosinophilic inflammatory disorders, massive accumulation of eosinophils within mucus is observed in certain cases, and is often linked to the distinctive clinical finding of mucus with high viscosity. Eosinophilic mucus is found in a variety of diseases, including chronic allergic keratoconjunctivitis, chronic rhinosinusitis encompassing allergic fungal sinusitis, eosinophilic otitis media, eosinophilic sialodochitis, allergic bronchopulmonary aspergillosis/mycosis, eosinophilic plastic bronchitis, and eosinophilic asthma. In these pathological conditions, chronic inflammation and tissue remodeling coupled with irreversible organ damage due to persistent adhesion of toxic substances and luminal obstruction may impose a significant burden on the body. Eosinophils aggregate in the hyperconcentrated mucus together with cell-derived crystals, macromolecules, and polymers, thereby affecting the biophysical properties of the mucus. This review focuses on the clinically significant challenges of mucus and discusses the consequences of activated eosinophils on the mucosal surface that impact mucus and persistent inflammation.

Allergic fungal rhinosinusitis: What we can learn from allergic bronchopulmonary mycosis

Allergic fungal rhinosinusitis (AFRS) and allergic bronchopulmonary mycosis (ABPM) are inflammatory disorders of the respiratory tract resulting from type 1 and 3 hypersensitivity reactions against fungi. The hallmark features of both diseases are eosinophil infiltration into the airway mucosa caused by localized type 2 inflammation and concomitant viscid secretions in the airways. Eosinophilic mucin-induced compression of adjacent anatomic structures leads to bone erosion and central bronchiectasis in the upper and lower respiratory tracts, respectively. Although these diseases share common features in their pathogenesis, they also exhibit notable differences. Epidemiologic findings are diverse, with AFRS typically presenting at a younger age, exhibiting less complicated bronchial asthma, and displaying lower total immunoglobulin E levels in laboratory findings compared with ABPM. Furthermore, despite their similar pathogenesis, the rarity of sinio-bronchial allergic mycosis in both AFRS and ABPM underscores the distinctions between these two diseases. This review aims to clarify the similarities and differences in the pathogenesis of AFRS and ABPM to determine what can be learned about AFRS from ABPM, where more is known.

Clinicomycological Profile of Fungal Rhinosinusitis in South India

Chronic rhinosinusitis (CRS) is widely prevalent globally. Fungal rhinosinusitis is a subtype which requires early detection by using appropriate tests and to make an accurate decision regarding the treatment modality. This study aims at determining the clinicomycological profile of fungal rhinosinusitis (FRS). A total of 105 patients with CRS were included in the study which was prospectively done during a time period of 18 months in a tertiary care hospital. All patients were subjected to CT scans and diagnostic nasal examinations (DNE) preoperatively. The sinonasal specimens were subjected to KOH mount, fungal culture and histopathological examination following functional endoscopic sinus surgery (FESS). 53% of the patients with fungal sinusitis belonged to the age group 41-60 years. The prevalence of FRS was found to be 38% with aspergillus species accounting for about 85% cases. FRS is a disease which can have a wide spectrum of clinical presentations requiring early detection and appropriate treatment which is essential to avoid both short term and long term sequalae.

A Clinico-Pathological Study of Allergic Fungal Rhinosinusitis at a Tertiary Care Center of Western Rajasthan

Allergic fungal rhinosinusitis (AFRS) is a non-invasive fungal sinusitis resulting from an immunologic response to the presence of extra mucosal fungal hyphae in the sinuses. Here we studied clinicopathological characteristics of AFRS among patients of chronic rhinosinusitis with nasal polyposis who underwent Functional Endoscopic Sinus Surgery (FESS) at a tertiary care in western Rajasthan. Standard ethical protocol was followed for the present study. We did a prospective study on admitted patients of chronic rhinosinusitis with nasal polyposis in the department of Otorhinolaryngology and Head & neck surgery, Dr. S. N. Medical College, Jodhpur from January 2018 to August 2019, who underwent FESS. The patient's history, clinical and endoscopic findings with radiological features were recorded. Biopsy specimens were sent for fungal staining, culture, and histopathology. As per Bent and Kuhn criteria, 25 cases out of 100 were diagnosed as AFRS, mean age was 27.46 ± 13.36. Nasal obstruction and nasal discharge were the most common symptoms. On histopathological examination fungal hyphae found in 18 cases (72%), allergic mucin in 25 cases (100%) and eosinophilic infiltrate in 20 cases (80%). Fungal culture positive in 15 cases (60%) of AFRS. In which aspergillus flavus present in 12 (80%). Allergic fungal rhinosinusitis should be considered as an important differential diagnosis in patients with chronic rhinosinusitis with nasal polyposis and for this surgery should be the treatment of choice.

Noninvasive fungal rhinosinusitis: a case series

Introduction: Fungal rhinosinusitis (FRS) remains a rare disease. The noninvasive forms are hard to diagnose. The management protocols remain controversial. We aim to describe the clinical, radiological and pathological features of noninvasive FRS and present our management protocol and follow-up results. Patients and methods: This descriptive study was conducted in the ear-nose-throat department of the university hospital, Taher Sfar in Mahdia, Tunisia. All patients who responded to the definition of noninvasive FRS (fungal balls and allergic fungal sinusitis) were included. The study was conducted over a three year period (May 2017 – April 2021). Results: Eleven patients were included in this study: four cases of fungal balls and seven cases of allergic fungal sinusitis. Patients presented with symptoms of chronic recurrent rhinosinusitis with no response to conventional treatments. Computed tomodensitometry scan showed opacification of the paranasal sinuses in all patients. Other signs were heterogeneous opacities, local calcifications and thinning of the bony walls of the sinuses. Histopathological findings were inflammatory polyps in all cases of allergic FRS with the presence of fungal hyphae in 42.8% of the cases. All patients underwent surgery after a median delay of 12 [6–24] months of the symptom’s onset. The used procedures were endoscopic middle meatal antrostomy for all patients, ethmoidectomy (81.8%) and sphenoidotomy (36.4%). None received systemic antifungals or corticosteroids with a favorable outcome in all cases. Conclusion: Symptoms of noninvasive FRS are nonspecific. The scan images contribute to the diagnosis, but the perioperative findings and the histopathological results remain crucial.  The management is mainly surgical.

[Presentation and management of allergic fungal rhinosinusitis in children]

Objective:To assess the presentation of allergic fungal rhinosinusitis（AFRS） in children and the role of long-term comprehensive therapy of endoscopic surgery combined with drug therapy. Methods:The 3 children with AFRS were routinely examined by nasal endoscopy, CT scan, MRI scan and allergen detection before surgery, and mycological and histomathological examination were performed on the secretions in the sinus and the mucosa of the affected sinuses. All the 3 patients underwent endoscopic surgery, preoperative and postoperative treatment with oral and nasal corticosteroid, nasal irrigation, and individualized anti-allergy therapy and immunotherapy. The patients were followed up for 3 to 12 months. Results:All 3 children had nasal polyps and headache, and 2 children had exophthalmos and facial asymmetry. There were typical CT and MRI findings on imaging. Serum total IgE were all elevated, and 2 cases were positive for fungal SIgE. All 3 children underwent endoscopic surgery. Fungal hyphae and spores were found in 1 child, and other fungi tests were positive in another 2 children. Postoperative facial asymmetry was relieved spontaneously, and mucosal swelling and polypoid changes were observed in 2 children. Conclusion:AFRS is a specific type of chronic rhinosinusitis that is not uncommon in children. Early diagnosis, prompt operation, standardized treatment and long-term follow-up are very important in the diagnosis and treatment of AFRS in children.

Discrepancies Between Clinical and Anatomic Causes of Death in Acute Invasive Fungal Sinusitis

CONTEXT.—

Acute invasive fungal sinusitis (AIFS) can be challenging to diagnose because of its varied clinical presentation.

OBJECTIVES.—

To evaluate the discrepancies between clinical and autopsy diagnoses in patients with histologic evidence of AIFS at a tertiary care center.

DESIGN.—

Autopsy cases with a pathologic autopsy diagnosis of AIFS from the past 20 years at a tertiary hospital were evaluated for clinicopathologic features. Modified Goldman classification was used to classify discrepant cases. Clinical history was also reviewed.

RESULTS.—

Of 7071 institutional autopsy cases during 20 years, 9 met inclusion criteria and demonstrated AIFS at autopsy. Angioinvasive fungal elements were histologically identified in all cases, with multiorgan involvement in most cases (6 of 9; 67%). Major clinicopathologic discrepancies were identified in 6 cases (67%).

CONCLUSIONS.—

AIFS is an uncommon diagnosis rendered at autopsy. There is a subset of cases that demonstrate discrepancy between the clinical impression and pathologic autopsy diagnosis. Antemortem diagnosis of AIFS can be challenging, especially in cases without prototypical clinical symptoms and positive fungal cultures. At autopsy, there was multiorgan involvement, supporting extensive tissue sampling to evaluate for AIFS, even in the setting of negative fungal cultures or lack of classic symptoms. These findings highlight the importance of the pathologist's role at autopsy in the definitive diagnosis of AIFS, especially in clinically equivocal cases.

Unusual case presentation of fungal ball infection causing diabetes insipidus and seizure disorder

Sphenoid sinus fungal ball (FB) is a noninvasive fungal infection affecting predominantly immunocompetent middle-aged female patients. Common clinical manifestations include headaches, postnasal drip, and nasal discharge. In this case report, we present a 56-year-old female with a 10-year history of occasional dizziness, vertigo, nystagmus, feeling disoriented and feeling her eyes moving rapidly. Complaints of restlessness, insomnia, anxiety, stress and anger were also present. Due to the nonspecific nature of her symptoms, a diagnosis of sphenoid sinus FB was overlooked. Definitive diagnosis was established after performing a nasal endoscopy and subsequent histopathological examination of the collected sinus tissues. The histopathology report disclosed Aspergillosis FB with chronic sinusitis. Due to the decade long delay in diagnosis and proper treatment, septal wall collapse occurred, with the patient developing diabetes insipidus with hyponatremia that led to a massive seizure and fall, resulting in multiple disc herniations. Surgical removal of the FA elicited a complete resolution of her symptoms and a full recovery.

Although fungal rhinosinusitis is a well recognized spectrum of diseases by ENT specialists, through this case report we hope to draw attention to this particular pathological entity within fungal infections, while simultaneously underlining the broad spectrum of symptoms with which it may manifest and the importance of including FA infections when considering the differential diagnosis in patients with long-standing chronic sinusitis.

[Unilateral diseases of the maxillary sinus]

Unilateral diseases of the maxillary sinus are among the most common rhinologic diagnoses. The diversity of these diseases can represent a challenge for the treating physician. The spectrum ranges from harmless maxillary sinus cysts that seldom require treatment, to highly aggressive malignant tumors. Special attention should be given to the management of inverted papilloma. These benign tumors are characterized by high recurrence rates and the potential for malignant transformation. The key to minimizing recurrence is precise surgical intervention. Other unilateral maxillary sinus diseases such as the antrochoanal polyp and the fungus ball (aspergilloma) are also discussed in depth.

Chronic Invasive Fungal Rhinosinusitis with Atypical Clinical Presentation in an Immunocompromised Patient

Invasive fungal rhinosinusitis (FRS) is a rare but intractable infectious disease of the sinonasal region with destructive direct infiltration into surrounding tissues, such as the bone, orbit and brain, and potential dissemination to systemic organs. Symptomatic assessments and imaging are frequently not sufficiently diagnostic, and histopathological examination is essential for definite diagnosis of FRS. We herein report a case of chronic invasive FRS (CIFRS) in a 58-year-old Japanese male with end-stage diabetic nephropathy that required maintenance dialysis after graft rejection of living kidney transplantation. His initial main clinical presentation was sinus gangrene, which gradually progressed from the paranasal sinus to the nasal septum and oral palate, but not towards the intracranial or orbital region, for two months. The patient was first strongly suspected to have extranodal natural killer/T cell lymphoma (ENKTL), nasal type, a subtype of malignant lymphoma, based on the macroscopic appearance of the gangrene, expansion pattern and high serum soluble interleukin-2 level; however, repeated biopsies and eventual resection led to diagnosis of CIFRS due to Aspergillus niger and Mucor. The disease was improved by surgical resection in combination with antifungal pharmacologic treatment with liposomal amphotericin B and voriconazole. CIFRS typically occurs in immunocompetent patients and shows intracranial progression, but this case shows that atypical CIFRS with an uncommon expansion pattern can occur in an immunodeficient patient.

Coagulase-negative staphylococci (CoNS) as a significant etiological factor of laryngological infections: a review

This review article shows that coagulase-negative staphylococci (CoNS) are widely responsible for laryngological diseases. General characteristics of CoNS infections are shown in the introduction, and the pathogenicity in terms of virulence determinants, biofilm formation and genetic regulation mechanisms of these bacteria is presented in the first part of the paper to better display the virulence potential of staphylococci. The PubMed search keywords were as follows: CoNS and: nares infections, nasal polyps, rhinosinusitis, necrosing sinusitis, periprosthetic joint infection, pharyngitis, osteomyelitis of skull and neck bones, tonsillitis and recurrent tonsillitis. A list of laryngological infections and those related to skull and neck bones was presented with descriptions of the following diseases: rhinosinusitis, necrotizing sinusitis, nasal polyps, nares and nasal skin infections, periprosthetic joint infections, osteomyelitis, pharyngitis, and tonsillitis. Species identification and diagnostic problems challenging for diagnosticians are presented. Concluding remarks regarding the presence of CoNS in humans and their distribution, particularly under the effect of facilitating factors, are mentioned.

Fungal Rhinosinusitis: Prevalence and Spectrum in Singapore

Background

Fungal involvement of the paranasal sinuses has been described more than two centuries ago. In the current article, it is referred to as fungal rhinosinusitis (FRS) which is a general term that is used to describe a spectrum of pathologically, immunologically, and clinically different disease entities affecting the paranasal sinuses where fungus is thought to be the major potential etiology.

Objective

To determine the incidence and spectrum of FRS in Singapore and to compare our findings with international figures through literature review.

Methods

A retrospective review of the clinical charts, radiological and laboratory results, and operative reports of all patients who underwent endoscopic sinus surgery at an ENT department of a tertiary referral hospital in Singapore over five-year period.

Results

Out of 533 functional endoscopic sinus surgeries performed during the period of the study for management of chronic rhinosinusitis, 44 (8.4%) were found to fit the criteria for diagnosis of FRS. Twenty (45.5%) were eosinophilic FRS and 24 (54.5%) were fungal balls. Invasive FRS has not been encountered. Clinical presentation, investigations, and management of both groups of patients are discussed.

Conclusion

Fungal rhinosinusitis is not uncommon in Singapore. Fungal ball and eosinophilic mucin fungal rhinosinusitis are among the most common forms encountered in this part of the world.

A Study on the Prevalence and Clinical Features of Fungal Sinusitis in Chronic Rhinosinusitis

Chronic sinusitis is a common disorder worldwide a significant proportion of which is secondary to fungal aetiology contrary to popular belief that fungal sinusitis is a rare entity, more so in a country like India where warm moist climate in a number of states and ever rising incidence of diabetes mellitus gives the fungal organisms a perfect environment to grow. This study aims to find the incidence and clinical features of fungal rhinosinusitis in chronic rhinosinusitis reinstating the fact that it should be kept as a differential diagnosis in every patient presenting with symptoms of chronic rhinosinusitis. Aim of the study was to find out the incidence and clinical manifestations of fungal sinusitis in chronic rhinosinusitis. A prospective study was conducted in JSS Academy of Higher Education and Research, Mysore during a time period of 37 months i.e. November 2015 to December 2018. Total of 190 patients with chronic rhinosinusitis were evaluated with relevant investigations to reach the diagnosis. All patients were subjected to diagnostic nasal endoscopy and CT scan of paranasal sinuses. Patients were then subjected to functional endoscopic sinus surgery and sample collected was sent for KOH stain and fungal culture with histopathology. Fungal rhinosinusitis is on the rise now and it is important to evaluate all cases with caution and keep an eye out for features suggestive of fungal sinusitis as an accurate diagnosis is the key to proper management.

[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.

Acute Invasive Fungal Rhinosinusitis in Immunocompromised Patients: Role of an Early Diagnosis

Objective

The aims of the present study were to evaluate the clinical significance of the delay for surgical treatment and the prognostic value of other clinical, pathologic, and microbiological variables among hematologic patients affected by acute invasive fungal rhinosinusitis (AIFRS). Furthermore, we propose our early diagnosis and treatment protocol, reporting its 10-year results.

Study Design

Monocentric retrospective analysis.

Setting

The study was conducted from 2001 to 2017 at the University Hospital of Bologna, Italy.

Subjects and Methods

The impact of time to treatment and clinical, pathologic, and microbiological variables were analyzed among patients with histologically and microbiologically proven AIFRS. The outcomes of patients treated before the introduction of the early diagnosis protocol were compared with those treated afterward.

Results

Nineteen patients affected by AIFRS were eligible for the study. Treatment delay >4 days ( P = .002), infection caused by Mucorales ( P = .015), and extension of the disease were negative prognostic variables ( P = .017). The application of our protocol significantly reduced the delay for diagnosis and appropriate treatment by an average of 7.3 days ( P = .02).

Conclusion

The promptness of the diagnosis and surgical treatment may play a significant role in the management of AIFRS, as it appears to be significantly associated with the disease outcome. Our protocol may help to reduce the time required for diagnosis of high-risk hematologic patients.

Eosinophilic Otitis Media: the Aftermath of Eosinophil Extracellular Trap Cell Death

PURPOSE OF REVIEW

Eosinophilic otitis media (EOM) is a refractory disease characterized by the accumulation of eosinophils in middle ear effusion and mucosa. We summarize current knowledge regarding the clinical characteristics and management of EOM. Although eosinophil activation in inflamed foci is involved in the pathogenesis of EOM, little is known about the fate of the eosinophils and aftermath of their cell death. We discuss the possibility that eosinophils undergo non-apoptotic cell death that worsens tissue damage and increases effusion viscosity.

RECENT FINDINGS

Unlike chronic otitis media, EOM is strongly associated with an allergic background. Corticosteroids are currently the only effective pharmacological treatment, and surgical intervention is often required. Mucosal eosinophils infiltrate extensively into the middle ear cavity where they are stimulated by locally produced activators including interleukin-5 and eotaxin. The eosinophils undergo cytolysis in the effusion, which represents a major fate of activated eosinophils in vivo. Recent data revealed cytolysis could be renamed as extracellular trap cell death (ETosis). ETosis represents suicidal cell death involving total cell degranulation and development of sticky chromatin structures (extracellular traps (ETs)). The characteristics of eosinophil- and neutrophil-derived ET polymers might contribute to the difference in viscosity of secretions between EOM and common chronic otitis media. The extracellular products remaining after eosinophil ETosis are an important aspect of EOM pathology. The concept of ETosis also has novel implications for potential therapeutic modalities in various eosinophilic disorders.

Identification of fungal causative agents of rhinosinusitis from Mashhad, Iran

Background and Purpose:

Rhinosinusitis is a common disorder, influencing approximately 20% of the population at some time of their lives. It was recognized and reported with expanding recurrence over the past two decades worldwide. Undoubtedly, correct diagnosis of fungi in patients with fungal rhinosinusitis affects the treatment planning and prognosis of the patients. Identification of the causative agents using the standard mycological procedures remains difficult and time-consuming.

Materials and Methods:

Based on clinical and radiological parameters, 106 patients suspected of fungal rhinosinusitis were investigated in this cross-sectional prospective study from April 2012 to March 2016 at an otorhinolaryngology department. In this study, internal transcribed spacer (ITS) and calmodulin (CaM) sequencing were respectively validated as reliable techniques for the identification of Mucorales and Aspergillus to species level (both agents of fungal rhinosinusitis).

Results:

Of these, 63 (59.4%) patients were suspected of allergic fungal rhinosinusitis (AFRS), 40 (37.7%) patients suspected of acute invasive fungal rhinosinusitis (AIFRS), and 3 (2.8%) patients suspected of mycetoma. In patients suspected of AFRS, AIFRS, and mycetoma only 7, 29, and 1 had positive fungal culture, respectively. After ITS and CaM sequencing, Aspergillus flavus was the most common species isolated from non-invasive forms, and A. flavus and Rhizopus oryzae were more frequently isolated from invasive forms.

Conclusion:

Aspergillus flavus is the most common agent of fungal rhinosinusitis in Iran, unlike most other reports from throughout the world stating that A. fumigatus is the most frequent causative agent of this disease.

A seven-year retrospective analysis of the clinicopathological and mycological manifestations of fungal rhinosinusitis in a single-centre tropical climate hospital

Objective:

To evaluate the clinicopathological and mycological manifestations of fungal rhinosinusitis occurring in the Tengku Ampuan Rahimah Hospital, in Klang, Malaysia, which has a tropical climate.

Methods:

Records of patients treated from 2009 to 2016 were analysed retrospectively. Data from the records were indexed based on age, gender, clinical presentations, symptom duration, clinical signs and mycological growth.

Results:

Of 80 samples, 27 (33.75 per cent) had fungal growth. Sixteen patients were classified as having non-invasive fungal rhinosinusitis and 11 as having invasive fungal rhinosinusitis. The commonest clinical presentation was nasal polyposis in non-invasive fungal rhinosinusitis patients (p < 0.05) and ocular symptoms in invasive fungal rhinosinusitis patients (p < 0.05). The commonest organism was aspergillus sp. (p < 0.05) in non-invasive fungal rhinosinusitis and mucorales in invasive fungal rhinosinusitis.

Conclusion:

There is an almost equal distribution of both invasive and non-invasive fungal rhinosinusitis, as seen in some Asian countries. Invasive fungal rhinosinusitis, while slightly uncommon when compared to non-invasive fungal rhinosinusitis, is potentially life threatening, and may require early and extensive surgical debridement. The clinical presentation of nasal polyposis was often associated with non-invasive fungal rhinosinusitis, whereas ocular symptoms were more likely to be associated with invasive fungal rhinosinusitis.

Direct identification of molds by sequence analysis in fungal chronic rhinosinusitis

Fungi are widely implicated in chronic rhinosinusitis. Direct microscopic examination (DME) is used to confirm the biological diagnosis of fungal rhinosinusitis (FRS). Diagnostic sensitivity of DME is better than culture, however DME does not allow fungal species identification. In this study, we included 54 sinus samples demonstrating hyphae on DME. Direct sequencing was compared to culture for the identification of the fungal species. Sequence analysis identified fungi in 81.5% of cases while culture was positive in only 31.5%. The most common genus was Aspergillus and the identified species belonged to section Fumigati or to section Flavi. Among other fungi identified by sequence analysis, Schizophyllum commune was present in three samples attesting to the importance of this Basidiomycetes in FRS. Our results clearly demonstrate the superiority of sequencing compared to culture when performed on specimens with hyphal elements at DME, and contributes to the epidemiological knowledge of fungi involved in FRS.

Eosinophil ETosis and DNA Traps: a New Look at Eosinophilic Inflammation

The traditional paradigm of eosinophils as end-stage damaging cells has mainly relied on their release of cytotoxic proteins. Cytokine-induced cell survival and secretion of granular contents from tissue-dwelling eosinophil are thought to be important mechanisms for eosinophilic inflammatory disorders, although the occurrence of cytolysis and its products (i.e., free extracellular granules) has been observed in affected lesions. Recent evidence indicates that activated eosinophils can exhibit a non-apoptotic cell death pathway, namely extracellular trap cell death (ETosis) that mediates the eosinophil cytolytic degranulation. Here, we discuss the current concept of eosinophil ETosis which provides a new look at eosinophilic inflammation. Lessons from eosinophilic chronic rhinosinusitis revealed that ETosis-derived DNA traps, composed of stable web-like chromatin, contribute to the properties of highly viscous eosinophilic mucin and impairments in its clearance. Intact granules entrapped in DNA traps are causing long-lasting inflammation but also might have immunoregulatory roles. Eosinophils possess a way to have post-postmortem impacts on innate immunity, local immune response, sterile inflammation, and tissue damage.

Revisiting the Utility of Histopathological Examination of Biopsy: A Necessity in Microbiology

INTRODUCTION

Culture is the gold standard, while potassium hydroxide mount is simplest technique used for diagnosis of fungal pathogens. Histopathological examination is the only definitive means to identify certain uncultivable fungi.

AIM

To analyse role of histopathological examination and potassium hydroxide (KOH) mount for diagnosing fungal infections by correlating them with culture.

MATERIALS AND METHODS

In this nine year retrospective study, all biopsy specimens submitted for microbiological examination were included. Histopathological examination of biopsies of cases with positive microbiological findings on either KOH mount or culture was carried out. Any discrepancy between histopathology interpretation and microbiology KOH or culture results, taking culture as the gold standard, were noted.

STATISTICAL ANALYSIS

Open Epi software was used for statistical analysis. Comparisons between groups were made by using the chi-square test. A p-value < 0.05 was considered statistically significant. Cohen's Kappa coefficient (κ) was calculated as a measure of agreement between different variables.

RESULTS

Concurrent pathology specimen could be obtained in 70 samples positive for fungal elements in either KOH or culture. Thirty-two cases were positive for fungi in culture, of which 16 were correctly identified by histopathological examination. Histopathological examination was strongly associated with culture result. KOH mount was in good agreement with positive culture result for yeast. Eleven culture negative but KOH and histopathology positive cases included seven samples with hyphae suggestive of zygomycosis, and two cases of rhinosporidiosis. Allergic mucin was strongly associated with Aspergillus species. KOH mount and detection of allergic mucin on histopathological examination were found to be excellent complementary tools for diagnosing Aspergillus species. Necrosis was highly specific for fungal growth in culture and had good positive predictive value.

CONCLUSION

We advocate using histopathology, culture and KOH examination in an integral manner to avoid potential lapses in patient management.

Fungal Rhinosinusitis: Microbiological and Histopathological Perspective

INTRODUCTION

On the basis of histopathology Fungal Rhinosinusitis (FRS) is categorized into non-invasive (allergic fungal rhinosinusitis, fungal ball) and invasive (acute invasive, chronic invasive and granulomatous invasive fungal sinusitis). This differentiation helps to decide the treatment. Role of latest molecular methods such as PCR and conventional methods such as KOH microscopy and culture also needs to be evaluated. Therefore, in this study we planned to categorise fungal rhinosinusitis on the basis of histopathology and compare it with other methods such as PCR, culture and KOH microscopy.

AIM

To analyse fungal rhinosinusitis cases by both histopathologically and microbiologically.

MATERIALS AND METHODS

A total of 76 clinically suspected fungal rhinosinusitis cases were included in the study. The tissue of suspected cases were processed and examined by KOH microscopy, histopathologically, culture and PCR. Histopathological examination was done by PAS, GMS and H&E stain.

RESULTS

FRS was diagnosed in 37 (48.68%) cases out of 76 clinically suspected cases of FRS. In which 17 (22.3%) cases were positive by direct microscopy, 21 (27.6%) by culture, 27 (35.5%) by PCR and 14 (18.42%) by histopathology. Approximately 14 cases of FRS were classified according to histopathology; 10 (71.3%) as non-invasive FRS. Out of these 10, 9 (64.2%) were classified as AFRS and 1 (7.14%) as fungal ball. Only 4 cases (28.5%) were diagnosed with invasive FRS. Out of these 4 cases, 2 (14.2%) were of chronic invasive fungal rhinosinusitis, 1 (7.14%) was of granulomatous invasive fungal rhinosinusitis and 1 (7.14%) was of acute fulminant invasive fungal rhinosinusitis. Allergic Fungal Rhinosinusitis (AFRS) is the most common type of FRS. Aspergillus flavus was found to be the most common fungi causing FRS.

CONCLUSION

Diagnosis should not be based on the single method. It should be done by both histopathological and microbiological methods, especially for those cases which are difficult to diagnose.

Expression of maspin in invasive fungal rhinosinusitis

OBJECTIVE

This study aimed to test the expression of maspin in invasive fungal rhinosinusitis and explore its value in diagnosing invasive fungal rhinosinusitis.

METHODS

Forty-two fungal rhinosinusitis cases (12 invasive and 30 non-invasive) were selected as the experimental group, and 30 chronic rhinosinusitis cases comprised the control group. Maspin expression was assessed in nasal mucous membrane specimens by immunohistochemical staining.

RESULTS

Compared with the control group, maspin expression was down-regulated in the fungal rhinosinusitis group (p < 0.05). Furthermore, the staining score for maspin was lowest in the invasive fungal rhinosinusitis group, as compared with both the non-invasive fungal rhinosinusitis group and the control group (p < 0.05). A maspin staining score of 5.70 was the critical value for diagnosis of invasive fungal rhinosinusitis, with sensitivity and specificity of 91.7 per cent and 88.3 per cent, respectively.

CONCLUSION

The results of this study suggest that the maspin staining score may be a biomarker for effective and rapid diagnosis of invasive fungal rhinosinusitis.

Unusual case of bilateral maxillary fungus ball

An otherwise healthy 34-year-old man was referred to our ear, nose and throat (ENT) clinic for a bilateral maxillary radiologic opacity. This condition was accidentally discovered with a panoramic radiography performed during a follow-up visit after a bilateral endodontic treatment. The patient did not report any specific sinonasal symptom such as purulent nasal discharge, loss of smell and cough, apart from an unspecific sinus pressure. The CT scans showed a bilateral inflammatory process into the maxillary-ethmoidal sinuses and an iron-like density within the maxillary sinuses, while nasal endoscopy showed purulent discharge in the ostiomeatal complex. The patient underwent functional endoscopic sinus surgery under general anaesthesia and the inflammatory material collected was histologically diagnosed as a rare case of bilateral fungus ball. The patient was dismissed the following day with no complications; there were not any sign of recurrence or symptoms during a 4 month follow-up.

Contribution of molecular tools for the diagnosis and epidemiology of fungal chronic rhinosinusitis

Chronic rhinosinusitis (CRS) rank second at chronic inflammatory diseases in industrialized countries and are an important public health concern. Diagnosis relies on a set of arguments including clinical signs, imaging, histopathologic and mycological analyses of sinus specimens, collected during nasal endoscopy. The sensitivity of fungal cultures is reported to be poor, even when direct examination is positive, thus the epidemiology of fungal chronic sinusitis is ill-known. This study evaluated the sensitivity of molecular diagnosis in 70 consecutive samples (61 patients with CRS) analysed at the University Hospital of Rennes during a 3-year period. DNA detection was performed using a conventional PCR method targeting the ITS1/ITS2 sequence and the resulting amplification products were sequenced. Fungal CRS was proven in 42 patients (69%), of which only 20 (48%) had a positive culture. 37/42 (88%) patients were diagnosed with a fungus ball, 3 with allergic fungal CRS and 2 with undetermined fungal CRS. PCR was positive in all 42 cases and direct sequencing allowed to identify fungi in all cases but one, and detected multiple infection in 3. Aspergillus fumigatus was present in 69% of patients; Cladosporium cladosporoides in 9.5%, Scedosporium sp., A. nidulans and A. flavus in 7% each. In 2/19 patients with negative direct examination, sequencing analysis revealed the presence of Capnobotryella sp. and C. cladosporoides, in clinical settings compatible with fungal sinusitis. In conclusion, ITS1/ITS2 PCR had a twice better sensitivity than culture, and combined sequencing provides accurate epidemiological data on fungal CRS.

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.

Nasal Cavity and Paranasal Sinuses

The nasal cavity and paranasal sinuses occupy the top of the upper respiratory tract and form pneumatic spaces connected with the atmosphere. They are located immediately beneath the base of the cranium, where crucial vital structures are harbored. From this region, very much exposed to airborne agents, arise some of the more complex and rare benign and malignant lesions seen in humans, whose difficulties in interpretation make this remarkable territory one of the most challenging in the practice of surgical pathology.

Contents of this chapter cover inflammations and infections, polyps and pseudotumors, fungal and midfacial destructive granulomatous lesions, as well as benign, borderline, and malignant neoplasms. Among the neoplasms, emphasis is made on those entities characteristic or even unique for the sinonasal region, such as Schneiderian papillomas, glomangiopericytoma, intestinal- and non-intestinal-type adenocarcinomas, olfactory neuroblastoma, nasal-type NK-/T-cell lymphoma, and teratocarcinosarcoma. Moreover, recently recognized entities involving this territory, i.e., HPV-related non-keratinizing carcinoma, NUT carcinoma, and SMARCB1-deficient basaloid carcinoma, are also discussed in the light of their specific molecular findings. Furthermore, the text is accompanied by numerous classical and recent references, several tables, and 100 illustrations.

Eosinophil extracellular trap cell death-derived DNA traps: Their presence in secretions and functional attributes

BACKGROUND

Activated human eosinophils, as well as neutrophils, can release extracellular chromatin to form DNA traps through cytolytic extracellular trap cell death (ETosis). Although formations of neutrophil DNA traps are recognized in patients with various inflammatory conditions, neither the presence of ETosis-derived eosinophil DNA traps in human allergic diseases nor the characteristics of these DNA traps have been studied.

OBJECTIVE

We investigated the presence of ETosis-derived DNA traps in eosinophil-rich sinus and ear secretions and the functional attributes of ETosis DNA traps.

METHODS

Eosinophil-rich secretions obtained from patients with eosinophilic chronic rhinosinusitis and eosinophilic otitis media were studied microscopically. In vitro studies of ETosis and DNA trap formation used blood-derived eosinophils and neutrophils, and studies of the binding capacities of DNA traps used labeled bacteria and fluorescent microbeads. Stabilities of DNA traps were evaluated by using fluorescence microscopy.

RESULTS

Abundant nuclear histone H1-bearing DNA traps formed in vivo in the eosinophilic secretions and contributed to their increased viscosity. In vitro, after brief shear flow, eosinophil ETosis-elicited DNA traps assembled to form stable aggregates. Eosinophil DNA traps entrapped bacteria and fungi and, through hydrophobic interactions, microbeads. In comparison with neutrophil-derived DNA traps, eosinophil DNA traps ultrastructurally exhibited thicker fibers with globular structures and were less susceptible to leukocyte-derived proteolytic degradation, likely because of the lesser protease activities of eosinophils.

CONCLUSIONS

In human allergic diseases local cytolysis of eosinophils not only releases free eosinophil granules but also generates nuclear-derived DNA traps that are major extracellular structural components within eosinophil-rich secretions.

Frequency of fungal agents identified in sinus samples from patients with clinically suspected rhinosinusitis

Fungal rhinosinusitis (FRS) is one of the most important rhinosinusoidal disorders, which involves a variety of etiological agents. We carried out a study to determine the frequency of fungal agents in sinus samples from patients with clinically suspected rhinosinusitis (RS). A total of 205 clinical samples were assessed from 174 patients with clinically suspected RS, of which 48 were positive for microscopic examination and culture, 47 were positive for direct examination but negative by culture, 4 were negative for direct examination but positive by culture, and 106 were negative for both methodologies. The main fungal agents isolated were Aspergillus spp. (32.7%), followed by Schizophyllum commune (28.8%). Sensitivity and specificity of the direct examination were 92.3% and 69.3%, respectively, and concordance between the direct examination and culture was 48.4%. This study indicated that both Aspergillus and S. commune appear to be the most important agents involved in the development of FRS.

Pretreatment of sinus aspirates with dithiothreitol improves yield of fungal cultures in patients with chronic sinusitis

BACKGROUND

Mold pathogens are a leading cause of chronic rhinosinusitis. Successful isolation of mold on culture is helpful in establishing a diagnosis and guiding therapy. Though mucolytic agents are commonly used in European countries, they are not part of everyday use in North America. In this case-control prospective study, we investigated the yield of fungal culture before and after treatment of sinus aspirates with the mucolytic agent dithiothreitol in a United States hospital.

METHODS

Over a 5-month period during 2011-2012, 359 sinus aspirates from 294 patients with symptoms suspicious for chronic sinusitis or allergic fungal sinusitis were collected. Aspirates were cultured on fungal medium before and after treatment with dithiothreitol.

RESULTS

Of the 359 pairs of cultures, 62 (17.3%) demonstrated mold growth on at least 1 of the plates, 9 (14.5%) of which grew more than 1 species of mold. A total of 75 molds were identified, 41 (54.7%) of which were successfully cultured only when the mucus was pretreated with dithiothreitol (p < 0.0001). Quantitatively, more colonies grew from dithiothreitol-treated mucus than from direct-inoculation (p < 0.0001).

CONCLUSION

This study confirms improved recovery of mold from sinus cultures after pretreatment of samples with dithiothreitol. Further studies are needed to correlate these findings with clinical outcome.

Role of fungi in the pathophysiology of chronic rhinosinusitis: an update

The pathogenesis of chronic rhinosinusitis (CRS) is multi-factorial with an infectious process likely at least partly involved. While bacteria have been proposed to play a critical role in CRS, fungi have also been implicated by some investigators, although the pathogenesis of fungi in CRS represents a significant controversy among rhinologists. Fungal-associated factors believed to be involved in CRS include the ability of fungi to induce significant inflammatory reactions by different means through inducing localized cytokine production in the sinonasal tract. Despite these observations, randomized, controlled studies on CRS patients using antifungal therapy have not resulted in significant improvement in CRS patients. The role of fungi in the pathogenesis of CRS remains controversial.

Allergic fungal sinusitis in children

Allergic fungal sinusitis (AFS) is a subtype of eosinophilic chronic rhinosinusitis (CRS) characterized by type I hypersensitivity, nasal polyposis, characteristic computed tomography scan findings, eosinophilic mucus, and the presence of fungus on surgical specimens without evidence of tissue invasion. This refractory subtype of CRS is of the great interest in the pediatric population, given the relatively early age of onset and the difficulty in managing AFS through commercially available medical regimens. Almost universally, a diagnosis of AFS requires operative intervention. Postoperative adjuvant medical therapy is a mainstay in the treatment paradigm of pediatric AFS.

Improving the detection of fungi in eosinophilic mucin: seeing what we could not see before

OBJECTIVE

To investigate the improvement in histologic detection of fungi with Gomori methenamine silver (GMS) stain by trypsin predigestion in the mucus of patients with chronic rhinosinusitis (CRS).

STUDY DESIGN

Prospective, single group, descriptive analysis.

SETTING

Multi-institutional.

SUBJECTS AND METHODS

Thirty-four sinus specimens from 12 surgical patients with CRS were stained with hematoxylin and eosin, GMS stain, GMS with trypsin digestion, immunofluorescence stains for chitinase, and anti-Alternaria. All patients received skin testing, total IgE serology, and radioallergosorbent tests (RAST) for 23 fungal-specific IgE antibodies.

RESULTS

The conventional GMS stain detected fungi in only 9 of 34 (27%) specimens. Predigesting the specimen with trypsin dramatically improved the visualization of fungi (31/34, 91%). The chitinase immunofluorescence visualized fungi in 32 of 34 (94%), and anti-Alternaria visualized 33 of 34 specimens (97%). Only 8 of 12 (75%) patients had detectable allergies.

CONCLUSIONS

This report describes a simple modification of the conventional GMS stain that can significantly improve the visualization of fungi on histology and explains the lack of detection in previous studies. These novel, more sensitive histologic methods reveal the presence of fungi within the eosinophilic mucin in allergic and also nonallergic CRS patients, further questioning a crucial role of an IgE-mediated pathophysiology.

Fungal rhinosinusitis: a retrospective microbiologic and pathologic review of 400 patients at a single university medical center

Fungal Rhinosinusitis (FRS) is a well known entity, but only in more recent times have the types of FRS been more fully defined. In this study, we evaluate the diagnosis of FRS in a single medical center. Cases were divided into 2 main categories, non-invasive and invasive. Non-invasive FRS included fungus ball (FB) and allergic fungal rhinosinusitis (AFRS). Invasive FRS included acute invasive fungal rhinosinusitis (AIFRS), chronic invasive fungal rhinosinusitis (CIFRS), and chronic invasive granulomatous fungal rhinosinusitis (CGFRS). Fungal culture data, if available was reviewed. 400 patients with FRS were identified. 87.25% were non-invasive (45% AFRS, 40% FB, and 2% combined AFRS and FB and 12.5% were invasive 11% AIFRS 1.2% CIFRS 0.5% CGFRS. One patient (0.25%) had combined FB/CGFRS. Aspergillus sp. or dematiaceous species were the most common fungi isolated in AFS while Aspergillus sp. was most common in FB and AIFRS. In our experience, most FRS is non-invasive. In our patient population, invasive FRS is rare with AIFRS representing >90% of cases. Culture data supports that a variety of fungal agents are responsible for FRS, but Aspergillus sp. appears to be one of the most common organisms in patients with FRS.

Allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis is a phenotype of chronic rhinosinusitis with nasal polyposis, characterized by type 1 hypersensitivity to fungi, eosinophilic mucin with fungal hyphae in sinus secretions, and propensity for mucocele formation and bone erosion. Although its differentiation from other forms of chronic polypoid rhinosinusitis with eosinophilic mucin is sometimes problematic, type 1 hypersensitivity is a component of the disease process. Medical and surgical management can be augmented by immunotherapy directed toward the patient's specific allergen sensitivities. The primary rationale for immunotherapy is to control the allergic diathesis that may be contributing to the patient's chronic sinus inflammation.

Endodontic treatment: a significant risk factor for the development of maxillary fungal ball

Objectives

The risk factors for maxillary fungal ball are largely unknown. The aim of this study was to determine whether endodontic treatment of maxillary teeth is a risk factor for fungal ball development in the maxillary sinus, and to identify other possible risk factors.

Methods

One hundred and twelve case patients diagnosed with maxillary fungal ball (FB group) and age and gender matched control patients diagnosed with chronic paranasal rhinosinusitis (PNS group) were included to determine associations between previous endodontic treatment and maxillary fungal ball. In addition, we reviewed the dental extraction status of maxillary teeth and the underlying disease in both groups to analyze the other risk factors for maxillary fungal ball.

Results

There were 36.3% of patients in the FB group and 16.1% in the PNS group showed evidence of endodontic treatment on the maxillary teeth (P<0.001). Even after correction for possible confounding factor - the frequency of dental extractions - the rate of endodontic treatment remained higher in the FB group. The mean number of endodontically treated maxillary teeth in the FB group and PNS group were 0.63 and 0.27, respectively (P=0.001). In addition, 20.5% of the patients in the FB group and 13.4% in the PNS group has diabetes mellitus (P=0.154).

Conclusion

Endodontic treatment on maxillary teeth was a significant risk factor for the development of fungal balls in the maxillary sinus.

Fungal rhinosinusitis: a clinicopathological study from South India

Fungal rhinosinusitis (FRS) is uncommon and accounts for 6-12% of culture or histologically proven chronic sinusitis. FRS may be acute or chronic. The aim of this paper was to study the histological features that contribute to the diagnosis and sub typing of FRS, using a retrospective review of all paranasal sinus mucosal biopsies from January 2005 to December 2008. The clinical features, predisposing conditions, imaging findings, and extent of the lesion were noted. The slides were reviewed with hematoxylin and eosin, Gomori's methenamine silver, and periodic acid Schiff stains. Culture reports were obtained wherever material was subjected to culture. There were 63 biopsies diagnosed as FRS (45.7%) out of 138 biopsies of chronic sinusitis in the study period. The FRS was classified as allergic in 15 (23.8%), chronic non-invasive (sinus mycetoma) in 1 (1.6%), chronic invasive in 10 (15.87%), granulomatous invasive in 19 (30%), and acute fulminant in 18 (28.5%) biopsies or surgical resections. Predisposing conditions were identified in 19 patients with diabetes mellitus as the commonest. Seventeen of the 18 patients with acute fulminant FRS had predisposing conditions. As per the results, the characteristic histological features were allergic mucin in allergic, fungal ball in chronic non-invasive, sparse inflammation and numerous hyphae in chronic invasive, non caseating granulomas with dense fibrosis in granulomatous invasive, and infarction with suppuration in acute fulminant FRS. Aspergillus sp. was the commonest etiologic agent. To conclude, predisposing risk factors were more common in invasive FRS than in non-invasive sinusitis and Aspergillus species was the most common etiologic agent.