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Chen A, Pietris J, Bacchi S, Chan W, Psaltis AJ, Selva D, Lim W. Imaging Features of Invasive Fungal Rhinosinusitis: A Systematic Review. Can Assoc Radiol J 2024; 75:601-608. [PMID: 38344986 DOI: 10.1177/08465371241227424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
Fungal rhinosinusitis (FRS) includes non-invasive and invasive subtypes with the latter having significant morbidity and mortality. This systematic review aims to identify the imaging features most correlated with invasive fungal rhinosinusitis (IFRS) and present a checklist of these features to aid diagnosis. PubMed, Embase, CENTRAL, and Science Direct were searched from inception to May 2023, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Primary research articles published in English describing the imaging features of IFRS were included. The systematic review was conducted in accordance with the PRISMA guidelines. Forty-eight articles were identified for inclusion. Six studies examined radiological features in acute invasive fungal rhinosinusitis (AIFRS), and 9 studies of chronic invasive fungal rhinosinusitis (CIFRS). A majority of studies did not specify whether IFRS cases were acute or chronic. On CT, bony erosion and mucosal thickening were the most common features. Other features include nasal soft tissue thickening, nasal cavity opacification, opacification of the affected sinus, and perisinus soft tissue infiltration. Extra-sinus extension was commonly observed on MRI, most often invading intraorbitally and intracranially. Other sites of extra-sinus extension included the cavernous sinus, pterygopalatine fossa, infratemporal fossa, masticator space, and facial soft tissue. IFRS is a condition with potential for high morbidity and mortality. Several radiological features are highly suggestive of IFRS. Early identification of high-risk radiological features using a checklist may aid prompt diagnosis and early treatment. Future research investigating the radiological differentiation between IFRS and other significant pathology including bacterial orbital cellulitis would be beneficial.
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Affiliation(s)
- Anni Chen
- Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Radiology, University of Adelaide, Adelaide, SA, Australia
| | - James Pietris
- Faculty of Medicine, University of Queensland, Herston, QLD, Australia
| | - Stephen Bacchi
- Royal Adelaide Hospital, Adelaide, SA, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, SA, Australia
- Department of Neurology, University of Adelaide, Adelaide, SA, Australia
| | - WengOnn Chan
- Royal Adelaide Hospital, Adelaide, SA, Australia
- South Australian Institute of Ophthalmology, University of Adelaide, SA, Australia
- Department of Ophthalmology, University of Adelaide, Adelaide, SA, Australia
| | - Alkis J Psaltis
- Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Otolaryngology Head and Neck Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Dinesh Selva
- Royal Adelaide Hospital, Adelaide, SA, Australia
- South Australian Institute of Ophthalmology, University of Adelaide, SA, Australia
- Department of Ophthalmology, University of Adelaide, Adelaide, SA, Australia
| | - WanYin Lim
- Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Radiology, University of Adelaide, Adelaide, SA, Australia
- Jones Radiology, Eastwood, SA, Australia
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Ji J, Roland LT. Invasive fungal rhinosinusitis: current evidence and research opportunities. Curr Opin Otolaryngol Head Neck Surg 2024:00020840-990000000-00137. [PMID: 39146258 DOI: 10.1097/moo.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs. RECENT FINDINGS New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed. SUMMARY Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.
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Affiliation(s)
- Jenny Ji
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
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Patel EJ, Ahmad M, Schwartz BS, van Zante A, Kersten R, Loftus P. Invasive Fungal Sinusitis in an Immunocompetent Patient After Sinus Surgery for Chronic Rhinosinusitis with Nasal Polyps and a Mycetoma. Laryngoscope 2024. [PMID: 38651570 DOI: 10.1002/lary.31463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/25/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Abstract
Acute invasive fungal sinusitis (AIFS) classically presents as an aggressive fungal infection that can spread beyond its origin in the sinuses in immunocompromised patients. Although there have been reports of AIFS in immunocompetent, non-diabetic patients, it is extremely rare and the true mechanism behind it is unknown. A thirty-eight year old immunocompetent, non-diabetic woman underwent bilateral ESS for chronic rhinosinusitis with nasal polyps at a tertiary care center and post-operatively developed AIFS. Patient underwent uncomplicated ESS, was packed with foam containing triamcinolone and discharged on steroid rinses and a prednisone taper. Surgical pathology demonstrated left-sided colonization with non-invasive fungal elements consistent with a mycetoma. She presented on post-operative Day 11 with headache and left-sided retro-orbital pain. A culture of her left nasal cavity grew Rhizopus spp and MRI demonstrated evidence of invasive fungal infection of left sphenoid mucosa as well as inflammatory changes in the left orbit centered at the orbital apex. She was started on amphotericin and underwent a left-sided debridement with biopsies which demonstrated angioinvasive fungal disease. Her vision in her left eye worsened to 20/800 and she was treated with transcutaneous retrobulbar injection of amphotericin B. After stable interval imaging she was discharged on a long-term course of antifungals. Extensive immunologic work-up was unremarkable. We describe a case of an immunocompetent patient who developed AIFS after sinus surgery for CRS and a mycetoma likely as a result of local immune suppression and post-surgical trauma. Laryngoscope, 2024.
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Affiliation(s)
- Evan J Patel
- Department of Otolaryngology-Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Meleha Ahmad
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Brian S Schwartz
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - Annemieke van Zante
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Robert Kersten
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Patricia Loftus
- Department of Otolaryngology-Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
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Dallalzadeh LO, Ediriwickrema LS, Fung SE, Men CJ, Kossler AL, Kupcha AC, Mawn LA, Burkat CN, van Landingham SW, Conger JR, Simmons B, Pham C, Akella SS, Setabutr P, Ho T, Couch SM, Kim JS, Demirci H, Korn BS, Kikkawa DO, Liu CY. Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study. Orbit 2024; 43:41-48. [PMID: 36880205 DOI: 10.1080/01676830.2023.2186435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/25/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM). METHODS In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality. RESULTS Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality. CONCLUSIONS Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.
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Affiliation(s)
- Liane O Dallalzadeh
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
| | - Lilangi S Ediriwickrema
- Division of Ophthalmic Plastic and Reconstructive Surgery, Gavin Herbert Eye Institute, UC Irvine, Irvine, California, USA
| | - Sammie E Fung
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
| | - Clara J Men
- Division of Oculoplastic and Orbital Surgery, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Andrea L Kossler
- Division of Oculoplastic and Orbital Surgery, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Anna C Kupcha
- Division of Oculoplastics and Orbital Disease, Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee, USA
| | - Louise A Mawn
- Division of Oculoplastics and Orbital Disease, Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tennessee, USA
| | - Cat N Burkat
- Oculoplastic, Orbital, & Cosmetic Facial Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Suzanne W van Landingham
- Oculoplastic, Orbital, & Cosmetic Facial Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Jordan R Conger
- Division of Ophthalmic Plastic and Reconstructive Surgery, Gavin Herbert Eye Institute, UC Irvine, Irvine, California, USA
| | - Brittany Simmons
- Division of Oculoplastic, Orbit, and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Chau Pham
- Division of Oculoplastic, Orbit, and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Sruti S Akella
- Oculoplastic and Reconstructive Surgery Service, Illinois Eye and Ear Infirmary, University of Illinois, Chicago, Illinois, USA
| | - Pete Setabutr
- Oculoplastic and Reconstructive Surgery Service, Illinois Eye and Ear Infirmary, University of Illinois, Chicago, Illinois, USA
| | - Tiffany Ho
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Steven M Couch
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology and Visual Sciences, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jane S Kim
- Division of Eye Plastic, Orbital and Facial Cosmetic Surgery, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Hakan Demirci
- Division of Eye Plastic, Orbital and Facial Cosmetic Surgery, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Bobby S Korn
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, California, USA
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, La Jolla, California, USA
| | - Catherine Y Liu
- Division of Oculofacial Plastic and Reconstructive Surgery, Viterbi Family Department of Ophthalmology, Shiley Eye Institute, UC San Diego, La Jolla, California, USA
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Roland LT, Humphreys IM, Le CH, Babik JM, Bailey CE, Ediriwickrema LS, Fung M, Lieberman JA, Magliocca KR, Nam HH, Teo NW, Thomas PC, Winegar BA, Birkenbeuel JL, David AP, Goshtasbi K, Johnson PG, Martin EC, Nguyen TV, Patel NN, Qureshi HA, Tay K, Vasudev M, Abuzeid WM, Hwang PH, Jafari A, Russell MS, Turner JH, Wise SK, Kuan EC. Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations. Int Forum Allergy Rhinol 2023; 13:1615-1714. [PMID: 36680469 DOI: 10.1002/alr.23132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.
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Affiliation(s)
- Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Christopher H Le
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Jennifer M Babik
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christopher E Bailey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Lilangi S Ediriwickrema
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California, Irvine, Irvine, California, USA
| | - Monica Fung
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joshua A Lieberman
- Department of Pathology and Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University Medical Center, Atlanta, Georgia, USA
| | - Hannah H Nam
- Division of Infectious Diseases, Department of Medicine, University of California, Irvine, Orange, California, USA
| | - Neville W Teo
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Penelope C Thomas
- Department of Radiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Blair A Winegar
- Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Abel P David
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Patricia G Johnson
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Elaine C Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Neil N Patel
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kaijun Tay
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Waleed M Abuzeid
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Aria Jafari
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew S Russell
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University Medical Center, Atlanta, Georgia, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
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Yang N, Zhang L, Feng S. Clinical Features and Treatment Progress of Invasive Mucormycosis in Patients with Hematological Malignancies. J Fungi (Basel) 2023; 9:jof9050592. [PMID: 37233303 DOI: 10.3390/jof9050592] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
The incidence rate of invasive mucormycosis (IM) in patients with hematological malignancies (HMs) is increasing year by year, ranging from 0.07% to 4.29%, and the mortality rate is mostly higher than 50%. With the ongoing pandemic of COVID-19, COVID-19-associated mucormycosis (CAM) also became a global health threat. Patients with high risk factors such as active HMs, relapsed/refractory leukemia, prolonged neutropenia may still develop breakthrough mucormycosis (BT-MCR) even under the prophylaxis of Mucorales-active antifungals, and such patients often have higher mortality. Rhizopus spp. is the most common genus associated with IM, followed by Mucor spp. and Lichtheimia spp. Pulmonary mucormycosis (PM) is the most common form of IM in patients with HMs, followed by rhino-orbital-cerebral mucormycosis (ROCM) and disseminated mucormycosis. The prognosis of IM patients with neutrophil recovery, localized IM and receiving early combined medical-surgical therapy is usually better. As for management of the disease, risk factors should be eliminated firstly. Liposome amphotericin B (L-AmB) combined with surgery is the initial treatment scheme of IM. Those who are intolerant to L-AmB can choose intravenous formulations or tablets of isavuconazole or posaconazole. Patients who are refractory to monotherapy can turn to combined antifungals therapy.
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Affiliation(s)
- Nuobing Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
- Tianjin Institutes of Health Science, Tianjin 301600, China
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Agarwal S, Gautam R, Kumar J, Garg A, Khurana N, Meher R, Wadhwa V, Goel R, Arora R. COVID-Associated Sinonasal Mucormycosis: Radiological Pathological Correlation and Prognostic Value of MR Imaging. Indian J Radiol Imaging 2022; 33:46-52. [PMID: 36855711 PMCID: PMC9968527 DOI: 10.1055/s-0042-1759639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Our aim was to assess the sinonasal magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) in coronavirus disease (COVID)-associated mucormycosis (CAM) and to correlate these with histopathology and patient outcome in terms of duration of hospital stay and survival at 10 weeks. Methods Twenty patients with histopathologically confirmed sinonasal CAM underwent MRI (including postcontrast T1-weighted and diffusion-weighted imaging). Histopathological findings (presence of coagulative necrosis, granulomatous reaction, and fungal burden) were recorded and all patients were followed up at 6 and 10 weeks. Statistical analysis was done using chi-square test and Fischer's exact test. Results Enhancement patterns seen in our subjects included homogeneous, heterogeneous, and lack of contrast enhancement (LOC), with LOC being the most common (65%). Diffusion restriction was found in 90% patients. Statistically significant correlation was found between LOC pattern and presence of coagulative necrosis ( p -value = 0.007), extent of fungal hyphae ( p -value = 0.047), and duration of hospital stay ( p -value = 0.004). Restricted diffusion was also seen to correlate with a high fungal load ( p -value = 0.007). Conclusion Our study describes the MRI findings of AIFRS in CAM and highlights the imaging features which may be surrogate markers for coagulative necrosis and fungal burden.
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Affiliation(s)
- Sheetal Agarwal
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Richa Gautam
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Jyoti Kumar
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India,Address for correspondence Jyoti Kumar, MD Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical CollegeJawaharlal Nehru Marg, New Delhi 110002India
| | - Anju Garg
- Department of Radiodiagnosis, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Nita Khurana
- Department of Pathology, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Ravi Meher
- Department of Otorhinolaryngology, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Vikram Wadhwa
- Department of Otorhinolaryngology, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India
| | - Ruchi Goel
- Department of Ophthalmology, Guru Nanak Eye Center and Maulana Azad Medical College, New Delhi, India
| | - Ritu Arora
- Department of Ophthalmology, Guru Nanak Eye Center and Maulana Azad Medical College, New Delhi, India
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Aggarwal A, Raj N, Bhardwaj K, Misra RN, Malik A, Bajaj S. A pictorial review of imaging manifestations of rhino-orbito-cerebral mucormycosis–emerging threat in COVID pandemic. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [PMCID: PMC8894831 DOI: 10.1186/s43055-022-00735-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Mucormycosis is an aggressive invasive fungal infection caused by mycocetes fungi. It is an opportunistic infection, associated with high morbidity and mortality. In the current era of COVID-19 pandemic, the entire world has witnessed a dramatic upsurge in cases of Mucormycosis. Paranasal sinuses are the commonest site to be affected with the tendency for rapid spread to orbit, face, and brain. Early diagnosis and prompt medical or surgical intervention are the only ways for preventing morbidity and saving precious lives. Imaging plays a crucial role not only in diagnosis but also in defining the extent of the disease for presurgical mapping. Black turbinate sign in the nasal cavity, mucosal thickening in paranasal sinuses with periantral invasion, and bony erosion are the early diagnostic signs. This pictorial review shall provide a comprehensive review of the various imaging manifestations of rhino-orbito-cerebral mucormycosis with a final proposed reporting checklist.
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Idowu OO, Soderlund KA, Laguna B, Ashraf DC, Arnold BF, Grob SR, Winn BJ, Russell MS, Kersten RC, Dillon WP, Vagefi MR. Magnetic Resonance Imaging Prognostic Findings for Visual and Mortality Outcomes in Acute Invasive Fungal Rhinosinusitis. Ophthalmology 2022; 129:1313-1322. [PMID: 35768053 DOI: 10.1016/j.ophtha.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 10/31/2022] Open
Abstract
PURPOSE To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS). DESIGN Retrospective cohort study. PARTICIPANTS Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020. METHODS A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality. MAIN OUTCOME MEASURE Identification of initial, preintervention MRI findings associated with visual and mortality outcomes. RESULTS The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; P < 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001). CONCLUSIONS Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality.
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Affiliation(s)
- Oluwatobi O Idowu
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Karl A Soderlund
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Benjamin Laguna
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Davin C Ashraf
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Benjamin F Arnold
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Seanna R Grob
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Bryan J Winn
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Matthew S Russell
- Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Robert C Kersten
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - William P Dillon
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - M Reza Vagefi
- Division of Oculofacial Plastic Surgery, Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
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10
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Kurokawa M, Kurokawa R, Baba A, Kim J, Tournade C, Mchugh J, Trobe JD, Srinivasan A, Bapuraj JR, Moritani T. Deadly Fungi: Invasive Fungal Rhinosinusitis in the Head and Neck. Radiographics 2022; 42:2075-2094. [PMID: 36178803 DOI: 10.1148/rg.220059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Invasive fungal rhinosinusitis (IFRS) is a serious infection that is associated with high morbidity and mortality rates. The incidence of IFRS has been increasing, mainly because of the increased use of antibiotics and immunosuppressive drugs. Rhino-orbital cerebral mucormycosis has recently reemerged among patients affected by COVID-19 and has become a global concern. The detection of extrasinus involvement in its early stage contributes to improved outcomes; therefore, imaging studies are essential in establishing the degree of involvement and managing the treatment properly, especially in immunocompromised patients. The common sites of extrasinus fungal invasion are the intraorbital, cavernous sinus, and intracranial regions. Fungi spread directly to these regions along the blood vessels or nerves, causing devastating complications such as optic nerve ischemia or compression, optic neuritis or perineuritis, orbital cellulitis, cavernous sinus thrombosis, mycotic aneurysm, vasculitis, internal carotid arterial occlusion, cerebral infarction, cerebritis, and brain abscess. IFRS has a broad imaging spectrum, and familiarity with intra- and extrasinonasal imaging features, such as loss of contrast enhancement of the affected region, which indicates tissue ischemia due to angioinvasion of fungi, and the surrounding anatomy is essential for prompt diagnosis and management. The authors summarize the epidemiology, etiology, risk factors, and complications of IFRS and review the anatomy and key diagnostic imaging features of IFRS beyond the sinonasal regions. ©RSNA, 2022.
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Affiliation(s)
- Mariko Kurokawa
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Ryo Kurokawa
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Akira Baba
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - John Kim
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Christopher Tournade
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Jonathan Mchugh
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Jonathan D Trobe
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Ashok Srinivasan
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Jayapalli Rajiv Bapuraj
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
| | - Toshio Moritani
- From the Division of Neuroradiology, Department of Radiology (M.K., R.K., A.B., J.K., C.T., A.S., J.R.B., T.M.), Department of Pathology, Michigan Medicine (J.M.), and Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Neurology (J.D.T.), University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109; and Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (R.K.)
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11
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Sharifi A, Akbari Z, Shafie’ei M, Nasiri N, Sharifi M, Shafiei M, Zand A. Retrobulbar Injection of Amphotericin B in Patients With COVID-19 Associated Orbital Mucormycosis: A Systematic Review. Ophthalmic Plast Reconstr Surg 2022; 38:425-432. [PMID: 35943425 PMCID: PMC9451608 DOI: 10.1097/iop.0000000000002256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Following COVID-19 infection a rising count of rhino-orbito-cerebral mucormycosis is observed, requiring orbital exenteration, a disabling lifetime affecting surgery. One of the potential interventions for globe salvage in these patients is retrobulbar injections of amphotericin B. This study was conducted to review protocols, outcomes, and side effects of retrobulbar injection of amphotericin B in patients with COVID-19 associated rhino-orbito-cerebral mucormycosis (CAM). METHODS The PubMed, Scopus, Web of Science, and Embase databases were searched using a comprehensive string of relevant keywords. All English studies with the confirmed diagnosis of CAM infection were included. We excluded all studies in which retrobulbar injection of amphotericin B was not implemented in any of the patients or there was a lack of clarified and detailed data about this procedure among participants. RESULTS A total of 647 cases had a history of retrobulbar injection(s) of amphotericin B in 13 reviewed studies with 3,132 subjects of CAM. The most common protocol was the retrobulbar injection of 1 ml of 3.5 mg/ml liposomal amphotericin B for 3 doses daily or on alternate days. We discerned that the globe salvage rate was 95.0% in eyes with a history of retrobulbar injection(s). The total rate of orbital exenteration was 14.9%, regardless of the history of retrobulbar injection of the drug. Other outcomes of this intervention were vision salvage and reduced major ophthalmic complaints, including pain, swelling, chemosis, ptosis, and ophthalmoplegia. The side effects of this intervention were not serious, and most of them were transient. They included swelling at the injection site, restriction of ocular motilities, exacerbation of orbital inflammation, and even intensification of visual impairment in a few cases. CONCLUSIONS Retrobulbar injection of amphotericin B should be considered a nearly safe and protective intervention against orbital exenteration in patients with CAM. It may also be effective in saving vision. Since the effectiveness of orbital exenteration in the survival of patients is not ascertained, retrobulbar injections can be considered an alternative intervention.
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Affiliation(s)
- Ali Sharifi
- Department of Ophthalmology, Shafa Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Akbari
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Shafie’ei
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Naser Nasiri
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Meraj Sharifi
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohadeseh Shafiei
- Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Amin Zand
- Department of Ophthalmology, Shafa Hospital, Kerman University of Medical Sciences, Kerman, Iran
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12
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Goel R, Arora R, Shah S, Chhabra M, Kumar J, Khurana N, Gupta S, Khanam S, Kumar S, Singh S, Meher R, Thakar M, Garg A. Clinico-Radiological-Pathological Correlation of Visual Loss in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis. Ophthalmic Plast Reconstr Surg 2022; 38:242-249. [PMID: 34919070 PMCID: PMC9093237 DOI: 10.1097/iop.0000000000002112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To correlate the clinical, radiological, and histopathological features in Covid-associated Rhino-orbito-cerebral mucormycosis cases presenting with acute visual loss. DESIGN Cross-sectional study. METHODS Covid-associated Rhino-orbito-cerebral mucormycosis cases with unilateral visual loss, planned for exenteration, underwent orbital and ophthalmological ocular examination. The available radiological sequences, doppler ultrasonography and histopathology findings were correlated with clinical manifestations. RESULTS The median age was 51 years and the male: female ratio was 3:1. All except one presented with unilateral ophthalmoplegia. The ocular media were hazy in 2 eyes. In 8 eyes, retinal changes were suggestive of occlusion of CRA (6), combined occlusion of CRA and central retinal vein (1), and myopic degeneration with hypertensive retinopathy (1). The contralateral eye showed retinal ischemic changes in one patient. Radiological imaging showed orbital apex involvement in the 10 affected eyes and one contralateral eye. Ipsilateral cavernous sinus thrombosis, diffusion restriction on MRI of optic nerve, internal carotid artery narrowing/thrombosis, and cortical watershed infarcts were seen in 8, 4, 4, and 2 cases, respectively. The blood flow in CRA and ophthalmic artery was absent or reduced in all the 10 affected eyes and in 1 contralateral eye. On histopathology, orbital fat necrosis, fungal hyphae, acute inflammation, granuloma formation, ischemic thrombosis of ophthalmic artery was observed in 10 specimens. CRA was patent in 9 and thrombosed in 1 eye. Optic nerve was ischemic in 8 and viable in 2 eyes. CONCLUSION Acute visual loss in ROCM cases is associated with orbital apex involvement and thrombotic ischemia of ophthalmic artery. Cessation of flow in CRA possibly occurs secondary to ophthalmic artery thrombosis.
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Affiliation(s)
- Ruchi Goel
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Ritu Arora
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Shalin Shah
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Mohit Chhabra
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Jyoti Kumar
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Nita Khurana
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
| | - Swati Gupta
- Department of Radiodiagnosis, Maulana Azad Medical College, New Delhi, India
| | - Samreen Khanam
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Sumit Kumar
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Sonam Singh
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Ravi Meher
- Department of Otorhinolaryngology, Maulana Azad Medical College, New Delhi, India
| | - Meenakshi Thakar
- Department of Ophthalmology (Guru Nanak Eye Centre), Maulana Azad Medical College, New Delhi, India
| | - Anju Garg
- Department of Radiodiagnosis, Maulana Azad Medical College, New Delhi, India
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13
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Ashraf DC, Idowu OO, Hirabayashi KE, Kalin-Hajdu E, Grob SR, Winn BJ, Vagefi MR, Kersten RC. Outcomes of a Modified Treatment Ladder Algorithm Using Retrobulbar Amphotericin B for Invasive Fungal Rhino-Orbital Sinusitis. Am J Ophthalmol 2022; 237:299-309. [PMID: 34116011 DOI: 10.1016/j.ajo.2021.05.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Davin C Ashraf
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Oluwatobi O Idowu
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Kristin E Hirabayashi
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Evan Kalin-Hajdu
- Department of Ophthalmology (E.K-H.), Université de Montréal, Montreal, Quebec, Canada
| | - Seanna R Grob
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Bryan J Winn
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - M Reza Vagefi
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA
| | - Robert C Kersten
- From the Department of Ophthalmology (D.C.A., O.O.I., K.E.H., S.R.G., B.J.W., M.R.V., R.C.K.), University of California San Francisco, San Francisco, California, USA.
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14
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Chiou CA, Yoon MK. An Update on Fungal Orbital Infections. Int Ophthalmol Clin 2022; 62:55-69. [PMID: 35325910 DOI: 10.1097/iio.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Imaging of COVID-19-associated craniofacial mucormycosis: a black and white review of the "black fungus". Clin Radiol 2021; 76:812-819. [PMID: 34364672 PMCID: PMC8316064 DOI: 10.1016/j.crad.2021.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/20/2021] [Indexed: 12/26/2022]
Abstract
A subset of diabetic COVID-19 patients treated with steroids, oxygen, and/or prolonged intensive care admission develop rhino-orbito-cerebral mucormycosis. Radiologists must have a high index of suspicion for early diagnosis, which prompts immediate institution of antifungal therapy that limits morbidity and mortality. Assessment of disease extent by imaging is crucial for planning surgical debridement. Complete debridement of necrotic tissue improves survival. Imaging features reflect the angioinvasive behaviour of fungal hyphae from the Mucoraceae family, which cause necrotising vasculitis and thrombosis resulting in extensive tissue infarction. Contrast-enhanced magnetic resonance imaging (MRI) is the imaging technique of choice. The classic “black turbinate” on contrast-enhanced imaging represents localised invasive fungal rhinosinusitis (IFRS). A striking radiological feature of disseminated craniofacial disease is non-enhancing devitalised and necrotic soft tissue at the orbits and central skull base. Sinonasal and extrasinonasal non-enhancing lesions in IFRS are secondary to coagulative necrosis induced by fungal elements. Multicompartmental and extrasinonasal tissue infarction is possible without overt bone involvement and caused by the propensity of fungal elements to disseminate from the nasal cavity via perineural and perivascular routes. Fungal vasculitis can result in internal carotid artery occlusion and cerebral infarction. Remnant non-enhancing lesions after surgical debridement portend a poor prognosis. Assessment for the non-enhancing MRI lesion is crucial, as it is a sole independent prognostic factor for IFRS-specific mortality. In this review, we describe common and uncommon imaging presentations of biopsy-proven rhino-orbito-cerebral mucormycosis in a cohort of nearly 40 COVID-19 patients.
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16
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Assiri AM, Ryu S, Kim JH. Concurrent diagnosis of sinus fungus ball and invasive fungal sinusitis: A retrospective case series. Mycoses 2021; 64:1117-1123. [PMID: 34170564 DOI: 10.1111/myc.13343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sinus fungal ball (SFB) is the most common type of non-invasive fungal sinusitis and develops mostly in immunocompetent individuals, whereas invasive fungal sinusitis (IFS), with high mortality, develops mostly in immunocompromised patients. SFB may progress to IFS depending on the patient's immune status and underlying diseases. OBJECTIVES To investigate the possibility of SFB progressing to IFS. PATIENTS/METHODS A total of 10 patients histopathologically diagnosed with concurrent IFS and SFB from January 2013 to December 2019 were enrolled. Their clinical characteristics, histopathology and clinical course information were obtained and compared with those of 56 patients with IFS alone and 617 patients with SFB alone. RESULTS Acute, chronic and chronic granulomatous IFS was diagnosed in two (20%), five (50%) and three (30%) patients, respectively. All patients had severe facial pain and/or headache, with the most common comorbidity being diabetes (n = 5, 50%). SFB was identified in the maxillary (60%) and sphenoid (40%) sinuses. The tissue culture was positive for Aspergillus species in five (50%) patients. Eight patients with chronic or chronic granulomatous IFS were successfully treated by debridement with voriconazole, and the two patients with acute IFS and severe neutropenia due to haematologic malignancy died. Compared to patients with IFS alone, patients with combined SFB and IFS were older, female dominant, and commonly had chronic or chronic granulomatous IFS. In addition, they were older and more commonly diabetic and immunocompromised than patients with SFB alone. CONCLUSIONS SFB may progress to IFS particularly in elderly and immunocompromised patients.
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Affiliation(s)
- Abdullah M Assiri
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Najran University, Najran, Saudi Arabia
| | - Sungseok Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Heui Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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17
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Lagos AE, García-Huidobro FG, Sepúlveda V, Cruz JP, González C, Callejas CA. Determination of variables for a more accurate diagnostic approach in suspected acute invasive fungal rhinosinusitis: A non-concurrent cohort study. Clin Otolaryngol 2021; 46:775-781. [PMID: 33548105 DOI: 10.1111/coa.13734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/04/2021] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe a group of patients with suspected acute invasive fungal rhinosinusitis (AIFRS) diagnosis, and identify factors associated with a greater risk of presenting this disease. DESIGN Non-concurrent cohort study. SETTING A single-centre non-concurrent follow-up of patients with suspected AIFRS between August 2015 and July 2018. PARTICIPANTS 50 inpatients referred due to suspected AIFRS at Hospital Clínico Universidad Católica based on the association of a predisposing factor (neutropenia/immunodeficiency/poorly controlled diabetes) with fever of unknown origin. MAIN OUTCOME MEASURE The primary outcome was AIFRS diagnosis, defined as a concordant tissue biopsy. RESULTS Acute invasive fungal rhinosinusitis was confirmed in 18% (9/50) of the evaluated patients. AIFRS was significantly associated with a positive galactomannan (P = .04), and a paranasal sinus MRI with lack of contrast enhancement (LoCE) (P = .04) orbit compromise (P = .03) or global extrasinusal extension (P = .04). LoCE and extrasinusal extension in the paranasal sinus/brain MRI were risk factors for AIFRS (OR 16; CI 1.2-210.6 and OR 12.75; CI 1.3-128.8, respectively). Conversely, a nasal endoscopy showing healthy mucosa was identified as a protective factor for AIFRS (OR 0.06; CI 0.007-0.57). CONCLUSIONS In patients with suspected AIFRS, we identified laboratory and radiologic variables associated with the disease, which may help for a more accurate diagnostic algorithm and approach in this population.
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Affiliation(s)
- Antonia E Lagos
- Department of Otolaryngology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Valeria Sepúlveda
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Pablo Cruz
- Department of Radiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia González
- Department of Otolaryngology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudio A Callejas
- Department of Otolaryngology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Sanguinetti M, Posteraro B, Beigelman-Aubry C, Lamoth F, Dunet V, Slavin M, Richardson MD. Diagnosis and treatment of invasive fungal infections: looking ahead. J Antimicrob Chemother 2020; 74:ii27-ii37. [PMID: 31222314 DOI: 10.1093/jac/dkz041] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Improved standards of care depend on the development of new laboratory diagnostic and imaging procedures and the development of new antifungal compounds. Immunochromatography technologies have led to the development of lateral flow devices for the diagnosis of cryptococcal meningitis and invasive aspergillosis (IA). Similar devices are being developed for the detection of histoplasmosis that meet the requirements for speed (∼15 min assay time) and ease of use for point-of-care diagnostics. The evolution of molecular tools for the detection of fungal pathogens has been slow but the introduction of new nucleic acid amplification techniques appears to be helpful, for example T2Candida. An Aspergillus proximity ligation assay has been developed for a rapid near-patient bedside diagnosis of IA. CT remains the cornerstone for radiological diagnosis of invasive pulmonary fungal infections. MRI of the lungs may be performed to avoid radiation exposure. MRI with T2-weighted turbo-spin-echo sequences exhibits sensitivity and specificity approaching that of CT for the diagnosis of invasive pulmonary aspergillosis. The final part of this review looks at new approaches to drug discovery that have yielded new classes with novel mechanisms of action. There are currently two new classes of antifungal drugs in Phase 2 study for systemic invasive fungal disease and one in Phase 1. These new antifungal drugs show promise in meeting unmet needs with oral and intravenous formulations available and some with decreased potential for drug-drug interactions. Novel mechanisms of action mean these agents are not susceptible to the common resistance mechanisms seen in Candida or Aspergillus. Modification of existing antifungal susceptibility testing techniques may be required to incorporate these new compounds.
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Affiliation(s)
- Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Brunella Posteraro
- Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy.,Istituto di Patologia Medica e Semeiotica Medica, Università Cattolica del Sacro Cuore Rome, Italy
| | - Catherine Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Frederic Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.,Institute of Microbiology, Department of Laboratory Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Monica Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Malcolm D Richardson
- Mycology Reference Centre Manchester, ECMM Excellence Centre of Medical Mycology, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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19
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Treatment outcomes in acute invasive fungal rhinosinusitis extending to the extrasinonasal area. Sci Rep 2020; 10:3688. [PMID: 32111952 PMCID: PMC7048759 DOI: 10.1038/s41598-020-60719-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 02/14/2020] [Indexed: 11/08/2022] Open
Abstract
Acute invasive fungal rhinosinusitis (AIFRS) can spread beyond the sinonasal cavity. It is necessary to analyze the association between the specific site involved in the extrasinonasal area and the survival rate to predict patient prognosis. We investigated 50 patients who had extrasinonasal lesions on preoperative gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) scan and underwent wide surgical resection of AIFRS. The specific sites with loss of contrast enhancement (LoCE) on Gd-enhanced MRI were analyzed for AIFRS-specific survival rate. The most common underlying disease was diabetes mellitus followed by hematological malignancy. The most common symptoms were headache and facial pain. Seven patients (14.0%) expired because of AIFRS progression. Poor prognosis was independently associated with LoCE at the skull base on preoperative MRI (HR = 35.846, P = 0.004). In patients with AIFRS extending to the extrasinonasal area, LoCE at the skull base was an independent poor prognostic factor.
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20
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Diagnosis and Treatment of Acute Invasive Fungal Sinusitis in Cancer and Transplant Patients. Curr Infect Dis Rep 2019; 21:53. [PMID: 31773398 DOI: 10.1007/s11908-019-0707-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Modern advances in oncologic and end-organ therapies have led to an increase in immunocompromised patients and a corresponding rise in acute invasive fungal sinusitis (AIFS). Here, we present a comprehensive medical and surgical approach to the diagnosis and management of immunocompromised cancer and transplant patients with AIFS. RECENT FINDINGS Aspergillus and Mucorales are the most common fungi to cause AIFS, though atypical fungal pathogens have been implicated particularly among patients on azole prophylaxis. Symptoms present in the majority of AIFS cases include fever, nasal congestion, and facial swelling. Nasal endoscopy and radiology are adjuncts to clinical exam with the gold standard diagnostic test still being histopathology, though molecular testing such as panfungal PCR is playing a larger role. The treatment of AIFS requires surgery, antifungal therapy, and reversal of immunosuppression. We recommend initiation of liposomal amphotericin B as an empiric therapy for AIFS, transitioned to targeted therapy when/if a fungal pathogen is identified. Goals of surgery include diagnostic sampling and debridement of necrotic tissue. Equally, if not more important, is reversal of underlying immune suppression. Immune-stimulating therapies hold promise for reducing mortality, but require additional study. Despite improvements in medical and surgical management of AIFS, mortality continues to approach 50%. Early diagnosis of this disease entity followed by aggressive surgical and medical management are important, including reversal of the underlying immunosuppression.
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21
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Chikley A, Ben-Ami R, Kontoyiannis DP. Mucormycosis of the Central Nervous System. J Fungi (Basel) 2019; 5:jof5030059. [PMID: 31288475 PMCID: PMC6787740 DOI: 10.3390/jof5030059] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/17/2022] Open
Abstract
Mucormycosis involves the central nervous system by direct extension from infected paranasal sinuses or hematogenous dissemination from the lungs. Incidence rates of this rare disease seem to be rising, with a shift from the rhino-orbital-cerebral syndrome typical of patients with diabetes mellitus and ketoacidosis, to disseminated disease in patients with hematological malignancies. We present our current understanding of the pathobiology, clinical features, and diagnostic and treatment strategies of cerebral mucormycosis. Despite advances in imaging and the availability of novel drugs, cerebral mucormycosis continues to be associated with high rates of death and disability. Emerging molecular diagnostics, advances in experimental systems and the establishment of large patient registries are key components of ongoing efforts to provide a timely diagnosis and effective treatment to patients with cerebral mucormycosis.
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Affiliation(s)
- Amanda Chikley
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Ronen Ben-Ami
- Infectious Diseases Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel.
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, The University of Texas, M.D. Anderson Cancer Center, Houston 77030, TexasTX 77030, USA.
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Choi YR, Kim JH, Min HS, Won JK, Kim HJ, Yoo RE, Kang KM, Park SW, Yun TJ, Choi SH, Sohn CH, Rhim JH, Kim SC, Ryu JW, Na DG. Acute invasive fungal rhinosinusitis: MR imaging features and their impact on prognosis. Neuroradiology 2018; 60:715-723. [DOI: 10.1007/s00234-018-2034-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/04/2018] [Indexed: 12/29/2022]
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23
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Fernandez IJ, Crocetta FM, Demattè M, Farneti P, Stanzani M, Lewis RE, Fornaciari M, Pasquini E, Sciarretta V. Acute Invasive Fungal Rhinosinusitis in Immunocompromised Patients: Role of an Early Diagnosis. Otolaryngol Head Neck Surg 2018; 159:386-393. [DOI: 10.1177/0194599818765744] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Ignacio Javier Fernandez
- Otorhinolaryngology Head and Neck Surgery Unit, Head and Neck and Sensory Organs Department, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesco Maria Crocetta
- Otorhinolaryngology Head and Neck Surgery Unit, Head and Neck and Sensory Organs Department, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marco Demattè
- Otorhinolaryngology Head and Neck Surgery Unit, Head and Neck and Sensory Organs Department, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Farneti
- Otorhinolaryngology Head and Neck Surgery Unit, Head and Neck and Sensory Organs Department, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marta Stanzani
- Haematology Unit “Istituto Seràgnoli,” Specialist Diagnostic and Experimental Medicine, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Russel E. Lewis
- Infectious Disease Unit, Department of Medical and Surgical Sciences, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Martina Fornaciari
- Otorhinolaryngology Head and Neck Surgery Unit, Head and Neck and Sensory Organs Department, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Ernesto Pasquini
- Otorhinolaryngology Head and Neck Surgery Unit, Head and Neck and Sensory Organs Department, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Vittorio Sciarretta
- Otorhinolaryngology Head and Neck Surgery Unit, Head and Neck and Sensory Organs Department, Sant’Orsola–Malpighi Hospital, University of Bologna, Bologna, Italy
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Roxbury CR, Smith DF, Higgins TS, Lee SE, Gallia GL, Ishii M, Lane AP, Reh DD. Complete surgical resection and short-term survival in acute invasive fungal rhinosinusitis. Am J Rhinol Allergy 2018; 31:109-116. [PMID: 28452707 DOI: 10.2500/ajra.2017.31.4420] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute invasive fungal rhinosinusitis (AIFR) is a fulminant fungal infection seen in patients who are immunocompromised. Due to its rarity, there is little evidence regarding the appropriate antifungal treatment regimen, especially the degree of surgical intervention. OBJECTIVE To assess factors that impact short-term survival in AIFR as defined by survival to hospital discharge and to develop a staging system to predict survival and complete surgical resection. METHODS Fifty-four patients with histopathologically diagnosed AIFR who met inclusion criteria were identified between 1984 and 2014. Patient characteristics, disease extent, treatment modality, and short-term survival data were collected. Univariate analysis was performed to assess for factors associated with survival and increased likelihood of surgical resection. RESULTS Of 52 patients with adequate documentation, 36 (69.2%) survived their hospital stay. Complete surgical resection was the only factor associated with improved survival (survival, 95.5%; p < 0.01). A surgical staging system was proposed to guide probability of complete resection and overall prognosis, with stage I disease limited to the nasal cavity, stage II involving the paranasal sinuses, stage III involving the orbit, and stage IV with skull base or intracranial extension. The χ2 analyses showed a decreased likelihood of complete surgical resection with stage III or IV disease compared with stage I (resection, 90.9%) (stage III resection, 37.5% [p = 0.01]; stage IV resection, 16.7% [p = 0.002]). There was a decreased likelihood of survival associated with increasing disease stage compared with stage I (survival, 100%) (stage II survival, 60% [p = 0.009]; stage III survival, 62.5% [p = 0.02]; stage IV survival, 54.6%, [p = 0.006]). CONCLUSION Although further studies are needed to define specific treatment protocols, analysis of these data indicated that endoscopic sinus surgery with the goal of complete surgical resection may provide the best survival outcomes in select patients when complete surgical resection can be performed. Our staging system represents the first attempt to predict surgical success and prognosis in patients with AIFR.
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Affiliation(s)
- Christopher R Roxbury
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Abstract
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.
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Ankrah AO, Sathekge MM, Dierckx RAJO, Glaudemans AWJM. Imaging fungal infections in children. Clin Transl Imaging 2016; 4:57-72. [PMID: 26913275 PMCID: PMC4752574 DOI: 10.1007/s40336-015-0159-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/15/2015] [Indexed: 12/16/2022]
Abstract
Fungal infections in children rarely occur, but continue to have a high morbidity and mortality despite the development of newer antifungal agents. It is essential for these infections to be diagnosed at the earliest possible stage so appropriate treatment can be initiated promptly. The addition of high-resolution computer tomography (HR CT) has helped in early diagnosis making; however, it lacks both sensitivity and specificity. Metabolic changes precede anatomical changes and hybrid imaging with positron emission tomography (PET) integrated with imaging modalities with high anatomical resolution such as CT or magnetic resonance imaging (MRI) is likely to detect these infections at an earlier stage with higher diagnostic accuracy rates. Several authors presented papers highlighting the advantages of PET/CT in imaging fungal infections. These papers, however, usually involve a limited number of patients and mostly adults. Fungal infections behave different in children than in adults, since there are differences in epidemiology, imaging findings, and response to treatment with antifungal drugs. This paper reviews the literature and explores the use of hybrid imaging for diagnosis and therapy decision making in children with fungal infections.
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Affiliation(s)
- Alfred O Ankrah
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO 9700 RB Groningen, The Netherlands ; Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
| | - Rudi A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO 9700 RB Groningen, The Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO 9700 RB Groningen, The Netherlands
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Davoudi S, Kumar VA, Jiang Y, Kupferman M, Kontoyiannis DP. Invasive mould sinusitis in patients with haematological malignancies: a 10 year single-centre study. J Antimicrob Chemother 2015; 70:2899-905. [PMID: 26188039 DOI: 10.1093/jac/dkv198] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/15/2015] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- S Davoudi
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA Department of Infectious Diseases, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - V A Kumar
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Jiang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M Kupferman
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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