Allergic Fungal Sinusitis: Expanding the Clinicopathologic Spectrum

Chronic Granulomatous Invasive Fungal Sinusitis in Patients With Immunocompetence: A Review

OBJECTIVE

We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease.

DATA SOURCES

Using specific keywords, we searched the PubMed, PubMed Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language.

REVIEW METHODS

Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with >5 cases each).

CONCLUSIONS

The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%. Aspergillus flavus (64%) was the most frequent isolate reported. Endoscopic excision (78.8%) followed by azole therapy was the preferred treatment in recent reports. Orbital exenteration and craniotomy were infrequently performed. Complete resolution or improvement was reported in 91.3% of patients. Mortality ranged from 5.9% to 22.2%. There is a trend in the literature toward less radical and disfiguring surgery and preferential use of azoles, with good outcomes even in advanced cases.

IMPLICATIONS FOR PRACTICE

Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.

The Role of Serum Galactomannan Assay as a Potential Surrogate Biomarker for Fungal Microinvasion in Allergic Fungal Rhinosinusitis

We conducted this study to determine if serum galactomannan (GM) can be used as a marker to implicate the invasiveness of allergic fungal rhinosinusitis (AFRS), and correlate this value with the aggressiveness of disease documented via computed tomography (CT). All paranasal CT scans done for AFRS patients prospectively over a five-year period (2015-2019) were included. An indigenous 20-point score was used to document the extent of bone erosion seen on CT, wherein a higher score meant a greater extent of bone erosion. It was then correlated with serum GM scores. The median CT scores of galactomannan-positive (GM+) patients were compared with the median CT scores of galactomannan-negative (GM-) patients 3 using Mann-Whitney U test. The patients were divided into five groups based on the extent of disease-No bone erosion, erosion of only sinus wall/orbit, 3 erosion of orbit and skull base, erosion of only skull base and lateral extension of disease into infratemporal fossa (ITF). Subgroup analysis was conducted over mean GM values in these groups using ANOVA test. p-value < 0.05 was considered significant. Statistical analysis was performed using SPSS version 25.0. A total of 92 patients were included (56 males, 36 females). No statistically significant difference was found (p-value = 0.42) between the CT scores of galactomannan-positive (GM+) group and galactomannan-negative (GM-) group. The mean GM scores amongst the five sub-groups did not show a statistically significant difference. Serum galactomannan values correlate poorly with aggressiveness of disease quantified on non-contrast CT of paranasal sinuses.

Low Incidence of Allergic Fungal Rhinosinusitis in Japanese Patients

Background:

Allergic fungal rhinosinusitis (AFRS) is a noninvasive fungal disease of the sinuses with a very high recurrence rate. A very small number of Japanese cases have been reported.

Material and methods:

The subjects were 6 patients with AFRS out of 429 patients who underwent endoscopic sinus surgery at Kagawa Rosai Hospital between December 2011 and November 2017. We retrospectively examined the clinical features and outcomes of these 6 patients.

Results:

The incidence of AFRS was 1.4% (6/429). Allergic fungal rhinosinusitis was unilateral in 5 cases and bilateral in 1. Computed tomography revealed hyperdense areas representing allergic mucin, but no patient exhibited bone erosion. Magnetic resonance imaging showed hypointense or no signal regions at the locations of allergic mucin. Postoperatively, 1 patient developed recurrence. Because the recurrent patient had no significant symptoms, he refused further surgery and received drug therapy. Preoperative eosinophil counts and total IgE levels were elevated in all patients; postoperatively, both remained high in the patient who developed recurrence. Postoperative treatments included steroid therapy and nasal irrigation.

Conclusions:

Allergic fungal rhinosinusitis is less prevalent in Japan than in Western nations. Peripheral blood eosinophil and serum IgE values may be used as the biomarkers.

Significance:

Allergic fungal rhinosinusitis is prone to recurrence. Postoperative treatment including steroid therapy is important in the management of AFRS.

Slowly progressive invasive rhino-orbito-cerebral aspergillosis: case report and literature review

This is a report of a patient with aspergillosis infection, which was thought to be a tumoral lesion during its investigation. This is not a common disease in Western countries, and this report should increase our awareness for differential diagnosis of nasal masses. Early diagnosis is desired in order to increase the survival rates.

Allergic Aspergillus Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a unique variety of chronic polypoid rhinosinusitis usually in atopic individuals, characterized by presence of eosinophilic mucin and fungal hyphae in paranasal sinuses without invasion into surrounding mucosa. It has emerged as an important disease involving a large population across the world with geographic variation in incidence and epidemiology. The disease is surrounded by controversies regarding its definition and etiopathogenesis. A working group on "Fungal Sinusitis" under the International Society for Human and Animal Mycology (ISHAM) addressed some of those issues, but many questions remain unanswered. The descriptions of "eosinophilic fungal rhinosinusitis" (EFRS), "eosinophilic mucin rhinosinusitis" (EMRS) and mucosal invasion by hyphae in few patients have increased the problem to delineate the disease. Various hypotheses exist for etiopathogenesis of AFRS with considerable overlap, though recent extensive studies have made certain in depth understanding. The diagnosis of AFRS is a multi-disciplinary approach including the imaging, histopathology, mycology and immunological investigations. Though there is no uniform management protocol for AFRS, surgical clearing of the sinuses with steroid therapy are commonly practiced. The role of antifungal agents, leukotriene antagonists and immunomodulators is still questionable. The present review covers the controversies, recent advances in pathogenesis, diagnosis, and management of AFRS.

Aspergillus terreus Meningitis in Immunocompetent Patient: A Case Report

We present a description of a rare but dangerous case of fungal meningitis caused by Aspergillus terreus in an immunocompetent patient with a history of sinus disease.

The potential hazards of Aspergillus sp. in foods and feeds, and the role of biological treatment: a review

The contamination of food and feed by Aspergillus has become a global issue with a significant worldwide economic impact. The growth of Aspergillus is unfavourable to the development of food and feed industries, where the problems happen mostly due to the presence of mycotoxins, which is a toxic metabolite secreted by most Aspergillus groups. Moreover, fungi can produce spores that cause diseases, such as allergies and asthma, especially to human beings. High temperature, high moisture, retarded crops, and poor food storage conditions encourage the growth of mold, as well as the development of mycotoxins. A variety of chemical, biological, and physical strategies have been developed to control the production of mycotoxins. A biological approach, using a mixed culture comprised of Saccharomyces cerevisiae and Lactobacillus rhamnosus resulted in the inhibition of the growth of fungi when inoculated into fermented food. The results reveal that the mixed culture has a higher potential (37.08%) to inhibit the growth of Aspergillus flavus (producer of Aflatoxin) compared to either single culture, L. rhamnosus NRRL B-442 and S. cerevisiae, which inhibit the growth by 63.07% and 64.24%, respectively.

Extensive Allergic Fungal Rhinosinusitis: Ophthalmic and Skull Base Complications

To review the clinical features, ophthalmic and skull base complications, radiologic correlates, surgical methods and outcomes in cases of extensive allergic fungal rhinosinusitis (AFRS). The retrospective review was carried out at a tertiary referral center and included 11 patients with extensive AFRS. Inclusion criteria were confirmed cases of AFRS with intracranial extension, gross erosion of the skull base or medial orbital wall and/or ophthalmic complications of AFRS, including visual loss. Acute bacterial or invasive fungal sinusitis and other non-AFRS sinus pathologies with orbital or skull base complications were excluded from the study. The mean age of patients was 22.7 years. Proptosis was the most common presenting feature followed by diplopia and visual loss. Four patients exhibited unilateral visual loss with one case of sudden acute onset. Intracranial extradural spread to the middle cranial fossa was observed in two cases with cavernous sinus involvement, destruction of the entire cranial base and extension to the petrous temporal bone. Ten patients exhibited co-existing orbital and skull base erosion whereas gross erosion of the lamina papyracea alone was seen in one patient. All patients underwent endoscopic sinus surgery with complete disease clearance. The minimum and maximum follow-up periods were 1 and 3 years, respectively with one documented recurrence 18 months after surgery. Visual recovery was complete after sudden vision loss whereas it was only partial or absent in patients with prolonged vision loss. Cases of extensive AFRS with ophthalmic and skull base complications pose diagnostic and therapeutic challenges and merit early intervention with long-term follow-up.

Allergic fungal sinusitis: innocence under suspicion

The objective of this investigation was to explore the possibility of treating patients harboring invasive intracranial aspergillosis (InIA) at an early stage. Nineteen patients (age range 18-42 years) from a total of 114 cases of InIA seen from January 1999- December 2009 were included in this investigation. These individuals, all of whom had a past history of treated allergic fungal sinusitis (AFS) were evaluated as to their immune status, clinical presentations, time-intervals and radiological findings. Past records of seven patients indicated skull base erosion and extension of the paranasal (PNS) masses into intracranial cavity, but none had neurological deficits or symptoms suggestive of raised intracranial pressure. All 19 patients had undergone endoscopic clearance of PNS during their first presentations. Both AFS and InIA were found simultaneously in seven patients, while the time-interval between the two forms was as long as 10 years for two patients. Overall mortality was (8/19; 42%) with all deaths attributable to fungal meningo-encephalitis. As InIA carries a high mortality rate, it seems prudent to evaluate and treat these patients early in the course of their illness. The appearance of the invasive form of the disease in patients with a past history of AFS is not uncommon. The allergic form of disease may not be considered as a separate entity from InIA as both the pathologies may exist in same patient.

Optic nerve compression in allergic fungal sinusitis

OBJECTIVE

To describe the syndrome of optic nerve involvement in cases of allergic fungal sinusitis.

SETTING

Academic tertiary care centre.

METHODS

Analysis of prospectively accrued data for 10 consecutive cases (three bilateral, giving 13 eyes) with visual loss secondary to optic nerve compression, from a total of 70 cases of allergic fungal sinusitis undergoing surgical treatment between June 1997 and May 2007.

RESULTS

The mean duration of rhinological symptoms prior to the onset of visual loss was 22 months. At presentation, visual loss ranged from a visual acuity of 6/12 to complete loss of light perception. Bilateral involvement was noted in three of the 10 cases. Urgent surgical decompression with removal of all fungal debris and decompression of the optic nerve resulted in visual recovery in seven of the 13 eyes. On univariate analysis, recovery was less likely in cases with long standing visual loss, and in cases with complete visual loss.

CONCLUSION

Long standing allergic fungal sinusitis may be complicated by visual loss due to compression of the optic nerve. Urgent surgery to clear the sinuses and decompress the optic nerve is successful in reversing visual loss in cases with partial visual loss.

Th1 and Th2 cytokines in a self-healing primary pulmonary Aspergillus flavus infection in BALB/c mice

Studies with non-immunocompromised mice have demonstrated that Aspergillus flavus is more virulent than almost all other Aspergillus species. However, the type of immune response this fungus induces in mammals has not been investigated thoroughly. The study was carried out to analyze the sequential pathogenesis of pulmonary A. flavus infection and the role of cytokines in host response in BALB/c mice. Two distinct phases were observed in mice: First, an intense rate of clearance of A. flavus occurred, most likely through recruited neutrophils and the resident alveolar macrophages with concurrent release of pro-inflammatory cytokines and second, fungal and cellular debris were cleaned by recruited monocytes, pro-inflammatory cytokine production rapidly decreased and infection self-healed. The pro-inflammatory cytokine IFN-γ demonstrated an upward trend up to 24h PI followed by a steady decline. The titers of TNF-α (a pro-inflammatory Th1 cytokine) were, however, inversely related to the titers of IL-10 an anti-inflammatory Th2 cytokine. The anti-inflammatory cytokine IL-4 showed slightly decreasing trend between 12 and 48 h PI, beyond that it again reached to the titers observed at 6h PI. The infected mice produced signs of Th1 type response with self healing capabilities.

Spectrum of fungal rhinosinusitis; histopathologist's perspective

AIMS

Clinical presentation can provide a clue to the subcategories of fungal rhinosinusitis (FRS); however, tissue examination provides accurate classification. The aim was to analyse the incidence and histopathological spectrum of FRS.

METHODS AND RESULTS

A retrospective analysis of all the cases of rhinosinusitis reported in the last 5 years was carried out. Haematoxylin and eosin-stained sections along with special stains such as periodic acid-Schiff and Grocott's were examined. These cases were subclassified based on the presence of allergic mucin, mycelial elements and tissue reaction. Out of a total of 665 cases of rhinosinusitis, 284 (42.7%) were of FRS. On histopathological examination they were broadly categorized as: (i) non-invasive FRS (n = 171, 60.2%), which included 160 cases (56.3%) of allergic fungal rhinosinusitis (AFRS) and eleven (3.9%) of fungal ball; (ii) invasive FRS (n = 101, 35.6%), which included 48 cases (16.9%) of chronic invasive granulomatous FRS, four (1.4%) of chronic invasive FRS and 49 (17.3%) of acute fulminant FRS; and (iii) mixed pattern FRS, comprising 12 cases (4.25%).

CONCLUSIONS

AFRS is the most common type of FRS. Cases with mixed reaction pattern suggest that different types of FRS represent a progressive spectrum of disease. An exact histopathological categorization of FRS is important as regards treatment.

Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies

BACKGROUND

Fungal (rhino-) sinusitis encompasses a wide spectrum of immune and pathological responses, including invasive, chronic, granulomatous, and allergic disease. However, consensus on terminology, pathogenesis, and optimal management is lacking. The International Society for Human and Animal Mycology convened a working group to attempt consensus on terminology and disease classification.

DISCUSSION

Key conclusions reached were: rhinosinusitis is preferred to sinusitis; acute invasive fungal rhinosinusitis is preferred to fulminant, or necrotizing and should refer to disease of <4 weeks duration in immunocompromised patients; both chronic invasive rhinosinusitis and granulomatous rhinosinusitis were useful terms encompassing locally invasive disease over at least 3 months duration, with differing pathology and clinical settings; fungal ball of the sinus is preferred to either mycetoma or aspergilloma of the sinuses; localized fungal colonization of nasal or paranasal mucosa should be introduced to refer to localized infection visualized endoscopically; eosinophilic mucin is preferred to allergic mucin; and allergic fungal rhinosinusitis (AFRS), eosinophilic fungal rhinosinusitis, and eosinophilic mucin rhinosinusitis (EMRS) are imprecise and require better definition. In particular, to implicate fungi (as in AFRS and EMRS), hyphae must be visualized in eosinophilic mucin, but this is often not processed or examined carefully enough by histologists, reducing the universality of the disease classification. A schema for subclassifying these entities, including aspirin-exacerbated rhinosinusitis, is proposed allowing an overlap in histopathological features, and with granulomatous, chronic invasive, and other forms of rhinosinusitis. Recommendations for future research avenues were also identified.

The role of allergy in rhinosinusitis

PURPOSE OF REVIEW

To examine the current evidence for IgE and non-IgE-mediated hypersensitivity mechanisms in acute and chronic rhinosinusitis.

RECENT FINDINGS

Epidemiological studies show that classical IgE-mediated allergy is present in a proportion of acute rhinosinusitis patients. There is conflicting evidence whether the prevalence of IgE-mediated allergy is greater in chronic rhinosinusitis than in individuals without chronic rhinosinusitis. Despite presence of classical IgE-mediated allergy, based on elevated allergen-specific serum IgE levels and positive skin prick tests, currently there is no direct evidence for allergy as a major cause of sinonasal inflammation in chronic rhinosinusitis. There is increasing evidence that non-IgE-mediated fungal hypersensitivity and nonallergic IgE-associated inflammation may contribute to the pathogenesis in some forms of chronic rhinosinusitis, including allergic fungal sinusitis. Specific IgE to bacterial superantigens may also be elevated in nasal polyps and modulate eosinophilic inflammation. Recent insights into mucosal immune mechanisms yield intriguing prospects for the roles of mucosal IgE, mast cells and non-IgE-mediated hypersensitivity mechanisms that require further examination in rhinosinusitis.

SUMMARY

There is a need for further immunological studies of the systemic and mucosal cellular and humoral mechanisms in well defined patient groups and controls to better understand the role of IgE and non-IgE-mediated hypersensitivity mechanisms and nonhypersensitivity functions of IgE in rhinosinusitis.

Controversies surrounding the categorization of fungal sinusitis

Though rhinosinusitis is a common disorder, controversies surround the categorization of chronic rhinosinusitis (CRS) and the role of fungus in CRS. The diagnosis of each category is important for optimum therapy and predicting the course. Based on histopathological findings, fungal rhinosinusitis (FRS) can be broadly divided into two categories: the invasive and non-invasive depending on invasion of the mucosal layer. Three types of FRS are tissue-invasive: acute invasive, chronic invasive, & granulomatous. The two non-invasive FRS disorders are fungal ball, and fungus related eosinophilic rhinosinusitis including allergic fungal rhinosinusitis (AFRS). The distinction of granulomatous from chronic invasive type is not beyond controversy as both types have a chronic course and predominant orbital involvement. Maximum confusion surrounds the entity of fungus-related eosinophilic rhinosinusitis, and the definition of AFRS. In the diagnosis of AFRS, the detection of fungi in allergic mucin is considered important, although hyphae are sparse in sinus content. This leads to confusion in definition of this entity, especially with the description of two more closely related entities--eosinophilic fungal rhinosinusitis (EFRS) and eosinophilic mucin rhinosinusitis (EMRS). Recently reports of histologic invasion in possible cases of AFRS were also documented. Currently, there are more questions than answers concerning the categorization of FRS.

Periocular infection

PURPOSE OF REVIEW

The aim of this article is to acquaint the clinician with advances in the diagnosis and management of periocular cellulitis and to alert physicians to emerging pathogens.

RECENT FINDINGS

The most important, recent infectious disease entity to consider is community-acquired methicillin-resistant Staphylococcus aureus, which is emerging as a significant problem across the country. The potential devastation caused by necrotizing fasciitis is also reviewed, since this diagnosis is easily missed early in its course. A variety of less common and frankly atypical pathogens is presented to remind the clinician that, on occasion, the hoofbeats are indeed a zebra's.

SUMMARY

Periocular cellulitis remains an important and common entity in ophthalmology. The emergence of new pathogens and the resistance to conventional treatment by others are a cause for concern and require an understanding of management strategies.

Eosinophilic mucus chronic rhinosinusitis: clinical subgroups or a homogeneous pathogenic entity?

BACKGROUND

Eosinophilic mucus chronic rhinosinusitis (EMCRS) can be subclassified using the criteria of detection of fungi in eosinophilic mucus and systemic fungal allergy. Allergic fungal sinusitis (AFS), a subgroup of EMCRS characterized by the presence of fungal allergy, is proposed to be an immunoglobulin (Ig)E-driven disease, distinct from other EMCRS subgroups. However, our recent studies cast doubt on the central pathogenic role of allergy in AFS. The purpose of this study was to examine the clinical features of EMCRS patients from the different subcategories to determine the relevance of this classification system.

METHOD

The demographic, clinical, and immunologic characteristics of the EMCRS subgroups were examined prospectively and compared with three control groups: healthy volunteers, allergic rhinitis with fungal allergy, and chronic rhinosinusitis without eosinophilic mucus.

RESULTS

EMCRS patients with allergy were younger than those without. There was no significant difference in clinicopathologic parameters between EMCRS subgroups. As a single group, EMCRS had a more severe sinus disease compared with chronic rhinosinusitis patients.

CONCLUSIONS

AFS was not clinically distinct from other subgroups of EMCRS. However, eosinophilic mucus may mark a more severe and distinct form of sinus disease.

Paranasal fungal sinusitis: contributions of histopathology to diagnosis: a report of 60 cases and literature review

Sixty cases of fungal sinusitis are presented from 2 institutions, accumulated from 1971 to 2005. Fifty cases were from a large suburban general hospital and 10 from a major university referral center. Two of the 50 and 3 of the 10, respectively, were immunocompromised patients and had acute fulminant disease. This suggests that encountering the various forms of this disease may, in part, be dependent on the referral nature of the institution. The remainder were immune competent and had chronic symptoms of nasal discharge, stuffiness, and facial pain. Imaging studies frequently showed sinus expansion, opacification, and bone erosion, although no clinical or radiographic features were predictive of extrasinus extension. Chronic fungal sinusitis is principally represented by fungus ball/mycetoma and allergic fungal sinusitis. The recent literature suggests a predominance of or a predominant interest in allergic fungal sinusitis. Hyphal colonies and the presence of allergic mucin with scattered organisms are histologic observations and are the respective keys to these diagnoses. However, the etiologic role of the fungus in chronic cases is not settled. Patients with chronic sinusitis who yield positive sinus cultures only, but have no organisms visualized histologically, are not universally regarded as having fungal sinusitis. The interest in fungal sinusitis has generated a prominent role for the pathologist. An awareness of the various forms of the disease and thorough histopathologic study, including submission of all tissues removed at surgery and recognition of allergic mucin, are essential. Acute fulminant/invasive fungal sinusitis may require frozen section for adequate management.

Overview of fungal rhinosinusitis

The incidence of fungal rhinosinusitis has increased to such extent in recent years that fungal infection should be considered in all patients with chronic rhino sinusitis. In India though the disease was reported earlier only from northern regions of this country, nowadays the disease is increasingly diagnosed from other parts as well. The disease has been categorized with possible five types: acute necrothing (fulminant), chronic invasive, chronic granulomatous invasive, fungal hall (sinus mycetoma), allergic. The first three types are tissue-invasive and the last two are non-invasive fungal rhinosinusitis. However, the categorization is still controversial and open to discussion. Chronic fungal rhinosinusitis can occur in otherwise healthy host and Aspergillus flavus is the common etiological agent in Indian scenario. The pathophys iologic mechanism of the disease remains unclear. It may represent an allergic IgE response, a cell-mediated reaction, or a combination of two. Early diagnosis may prevent multiple surgical procedures and lead to effective treatment. Histopathology and radio-imaging techniques help to distinguish different types and delineate extension of disease process. Culture helps to identify the responsible etiological agent. The presence or absence oj precipitating antibody correlates well with disease progression or recovery. The most immediate need regarding management is to establish the respective roles of surgery and antifungal therapy. Non-invasive disease requires surgical debridement and sinus ventilation only, though, additional oral or local corticosterold therapy may be beneficial in allergie type. For invasive disease, the adjuvant medical therapy is recommended to prevent recurrence and further extension. Itraconazole has been found as an effective drug in such situation. Patients with acute neerotizing type require radical surgery and amphotericin B therapy.