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

Imaging Features of Invasive Fungal Rhinosinusitis: A Systematic Review

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.

Combination endoscopic surgical debridement and transcutaneous retrobulbar amphotericin B for acute rhino-orbital-cerebral aspergillosis

PURPOSE

To report a case of acute rhino-orbital-cerebral aspergillosis with aggressive intracranial and orbital extension co-managed medically and surgically with endoscopic sinus debridement and multiple retrobulbar injections of amphotericin B.

OBSERVATIONS

A 70-year-old male patient presented via external transfer with headaches and left ophthalmoplegia concerning for severe complicated sinusitis with intracranial and left orbital spread. His history is notable for a simultaneous heart-kidney transplant three years prior on chronic immunosuppression. Ophthalmologic examination revealed complete ophthalmoplegia in the left eye with no light perception concerning for a left orbital apex syndrome. The patient was taken to the operating room twice for endoscopic sinus debridement and three separate retrobulbar injections of amphotericin B. Fungal cultures from surgical specimens grew isolated Aspergillus fumigatus. Patient's symptoms gradually improved and repeat MRI demonstrated resolution of pansinusitis, sparing left eye exenteration.

CONCLUSIONS AND IMPORTANCE

Multidisciplinary management of invasive fungal rhinosinusitis in the setting of profound immunosuppression poses a significant challenge. While surgical debridement remains the cornerstone approach, the achievable reduction in disease burden may be augmented by targeted retrobulbar antimicrobials.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations

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.

Invasive Fungal Rhinosinusitis: Clinical and Surgical Factors Affecting Its Prognosis and Disease-Specific Morality

PURPOSE

The purpose of this study is to discover factors that determine mortality in patients with invasive fungal rhinosinusitis.

METHODS

This retrospective study included 17 patients diagnosed with invasive fungal rhinosinusitis and who had undergone treatment in our department, including both surgical and medical management between January 2020 and October 2020. There were four male patients and 13 female patients whose mean age was 46 ± 15.67 years, ranging from 20 to 70 years. All the patients were immune-compromised because of diabetes mellitus. We studied the factors affecting the mortality of patients affected with this disease; it included the extent of disease (paranasal sinus, palatal, orbital, or intracranial involvement), serum glucose level (SGL), and C-reactive protein (CRP) levels.

RESULTS

Only one patient had paranasal sinus involvement alone, but the patient became disease-free after treatment. The disease-specific mortality rate was two (33.3%) of six patients with palatal involvement and four (50%) of eight patients with intracranial involvement where four patients did not have disease control at the time of discharge and did not follow up. The death rate in orbital involvement was 20% (three of 15 patients) and five patients with intra-orbital involvement left the hospital against medical advice. The analysis of data demonstrated that only intracranial (p = 0.01) involvement in addition to the nasal cavity and paranasal sinus involvement had a statistically significant effect on survival rate unlike intra-orbital (p = 0.510) and palatal involvement (p = 0.171).

CONCLUSION

Early endoscopic nasal inspection, diagnosis, and treatment are critical for disease-specific mortality in invasive fungal rhinosinusitis since orbital or cerebral involvement is linked to a poor prognosis. Patients who come with uncontrolled diabetes and ophthalmological and palatal involvement with positive findings on nasal examination should necessitate urgent histopathological and radiological workup.

Pediatric invasive fungal rhinosinusitis

Pediatric invasive fungal rhinosinusitis (PIFR) is a rapidly progressive, potentially fatal disease. Previous medical literature demonstrates that its early diagnosis significantly reduces the risk of mortality in these patients. This study aims to present an updated clinical algorithm for optimized diagnosis and management of PIFR. A comprehensive review was conducted with only original, full-text articles published in English and Spanish from Cochrane Library, Pub-Med/MEDLINE, Embase, Scopus, and Google Scholar between January 2010 and June 2022. Relevant information was extracted and then integrated to develop a clinical algorithm for a proper diagnosis and management of PIFR.

Study of Clinicoepidemiology and Surgical Complications in Acute Invasive Fungal Rhinosinusitis

To study clinicoepidemiology and surgical complications in acute invasive fungal rhinosinusitis. Retrospective observational study carried in GMC Akola from February 2021 to April 2022. Detailed history and clinical examination, nasal endoscopic biopsy or swab for KOH and fungal culture was taken. CECT/MRI PNS + Orbit + Brain was done. All patients underwent surgery and tissue sample send for histopathological examination. Total 146 patients included in study with M:F ratio 1.7:1. Most affected age group was between 40 and 60 years. 107 (78.6%) patients had history of COVID-19.Mucorale is most commonly found fungal species (90.4%) followed by aspergillus (2.7%) & mixed species (6.8%). Diabetes Mellitus is most common comorbidity. Intraoperative complications were bleeding (72.60%), CSF leak (4.1%), orbital hematoma (0.68%), nasolacrimal duct trauma (2.05%), periorbital hematoma (0.68%). Post operative complications like synechiae (56.16%), OAF (45.89%), hypoesthesia (25.34%), decreased vision (16.43%), facial pain (20.54%), facial deformity (20.54%), diplopia (6.8%), headache (30.13%), anosmia (39.72%), dental pain (20.54%), earache (9.58%), hyposmia (45.89%), periorbita ecchymosis (0.68%), residual disease (16.10%), recurrence (2.05%), death (2.05%) was observed. Prompt surgical debridement of devitalized tissue and early adequate dosage of antifungal (inj. Amphotericin-b) treatment are necessary as delay in surgical debridement and treatment can worsen the prognosis of disease. Among all complications faced maximum were manageable with early interventions but few of them were inevitable due to extensive nature of disease.

Orbital Complications of Acute Invasive Fungal Rhinosinusitis: A New Challenge in the COVID-19 Convalescent Patients

Purpose

Increased incidence of acute invasive fungal rhinosinusitis (AIFR) in the setting of COVID-19 is undeniable. This can be attributed to its effect on innate immunity and extensive use of corticosteroids. The goal of our study was to assess the orbital complications of AIFR and its management in the COVID-19 convalescent patients.

Methods

Our longitudinal prospective study included 45 patients with orbital complications of AIFR in recently recovered COVID-19 patients. We performed otorhinolaryngological, ophthalmological, and neurological examinations to monitor the manifestations of the disease. Computed tomography and contrast enhanced magnetic resonance imaging were performed to detect the extent of infection. Antifungal medications, surgical intervention, and general condition management were all provided to all the patients.

Results

We reported pre-septal cellulitis, orbital cellulitis, and orbital apex syndrome in 18, 13, and 10 patients, respectively. Four patients had cavernous sinus thrombosis. Mucormycosis and Aspergillus species were detected in 80% and 11.11% of our patients, respectively, while the mixed infection was found in 8.88% of our patients. Diabetes mellitus was the most common cause of immunocompromise (95.55% of our patients). Orbital pain and ophthalmoplegia were the most common ocular manifestations, followed by proptosis and relative afferent pupillary defect. All patients underwent surgical intervention, except for one patient who was unfit for surgery. One patient had orbital exenteration. The ophthalmological manifestations were reversible in cases of orbital and pre-septal cellulitis. The overall survival rate was 66.67%.

Conclusion

Early diagnosis and treatment of AIFR can decrease the morbidity and mortality rate of affected patients.

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

PURPOSE

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

DESIGN

Retrospective, comparative clinical study with historical control subjects.

METHODS

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

RESULTS

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

CONCLUSION

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

COVID-19-related acute invasive fungal rhinosinusitis: risk factors associated with mortality

Background

Acute invasive fungal rhinosinusitis (AIFRS) is a rare aggressive life-threatening infection that affects immunocompromised individuals. Recently, an increase in the incidence of this infection has been reported in patients who have SARS-CoV-2 infection or recently recovered. This study was to assess the outcome and define risk factors that might affect the outcome in SARS-CoV-2-related AIFRS. A prospective observational study included 54 patients diagnosed with SARS-CoV-2-related AIFRS. Controlling the predisposing factors, systemic antifungal, and early surgical debridement was performed. The mortality rate was calculated. Age, sex, underlying risk factors, the extent of the disease, debridement technique, and other biochemical variables were evaluated regarding their impact on survival. Patients were followed up for 3 months.

Results

Fifty-four patients with a mean age of 48.1 years. Diabetes mellitus was the most common comorbidity affecting 52 patients (96.3%). Intracranial and intraorbital extension had a predictive value for mortality (P value 0.050 and 0.049 respectively). However, only intracranial extension was the independent predictor of mortality. Biochemical variables were higher than the normal range, but only serum ferritin level above 165 ng/ml was an independent predictor of mortality in patients with AIFR. The mortality rate was 38.9%.

Conclusion

The extent of the disease has a major impact on survival, so early diagnosis of AIFRS within patients infected with SARS-CoV-2 or recently recovered is essential to reduce mortality.

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

OBJECTIVE

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

METHOD

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

RESULT

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

CONCLUSION

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

COVID-19 associated mucormycosis: Staging and management recommendations (Report of a multi-disciplinary expert committee)

Even before the onslaught of COVID-19 pandemic could settle, the unprecedented rise in cases with COVID-19 associated mucormycosis pushed the medical health to the fringe. Hyperglycaemia and corticosteroids appear to be the most consistent associations leading to the commonest manifestation of mucormycosis, Rhino-Orbito-Cerebral Mucormycosis. To address challenges right from categorisation and staging of the disease to the management of relentless progression, a multi-disciplinary expert committee was formed to handle the task in an evidence-based format to enforce best practices. The report of the committee on one hand attempts to succinctly present the currently available evidence while at the other also attempts to bridge the evidence-deficient gaps with the specialty-specific virtuosity of experts.

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

CONTEXT.—

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

OBJECTIVES.—

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

DESIGN.—

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

RESULTS.—

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

CONCLUSIONS.—

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

Invasive Fungal Rhinosinusitis with and without Orbital Complications: Clinical and Laboratory Differences

Background: Invasive fungal rhinosinusitis (IFS) is a rare but often fatal disease. There are limited studies regarding IFS with orbital complications (IFSwOC). The present study aimed to identify the clinical signs associated with IFSwOC and prognosticators of the disease. Methods: A retrospective case series was conducted of patients histopathologically confirmed IFS or fungal rhinosinusitis with clinically apparent neuro-orbital complications who underwent surgery between 2008 and 2018. Demographic data, presenting symptoms and signs, culture data, laboratory results, and patient outcomes were obtained from medical records. Results: A total of 38 patients were identified, including 9 patients with IFSwOC, and 29 patients with IFS without orbital complications (IFSsOC). The clinical signs associated with developing orbital complications include headache, fever, sphenoid sinus, or posterior ethmoid sinus involvement, CRP level ≥ 1.025 mg/dL, or ESR level ≥ 46.5 mm/h. In IFSwOC group, male, posterior ethmoid sinus involvement, WBC count ≥ 9000 μL, CRP level ≥ 6.91 mg/dL, or ESR level ≥ 69 mm/h were correlated with a significantly poorer prognosis. Conclusion: IFS patients with sphenoid or posterior ethmoid sinus involvement, headache or fever as presenting symptoms, elevated CRP, and ESR level were at risk of developing orbital complications. Timely surgical debridement followed by systemic antifungal treatment may improve treatment outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Detecting serum galactomannan to diagnose acute invasive Aspergillus sinusitis: a meta-analysis

PURPOSE

The serum galactomannan test has been used for diagnosing acute invasive fungal sinusitis (AIFS), especially invasive Aspergillus. We aimed to assess the accuracy of the test to diagnose acute invasive Aspergillus sinusitis (AIAS).

METHODS

We searched all relevant articles published in PubMed, Embase, the Cochrane Library, and Web of Science databases up until September 14, 2020. The available data for serum galactomannan test to diagnose AIAS from selected studies were assessed. The diagnostic odds ratio (DOR), summary receiver operating characteristics (SROC), sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were estimated. Additionally, we analysed four studies with a cut-off value of 0.5.

RESULTS

Five eligible articles were selected in this study. The total number of enrolled patients was 118, and 62 patients had confirmed AIAS. Among these 62 patients, the summary estimates of the serum galactomannan assay were as follows: DOR, 3.37 (95% confidence interval [CI]: 1.47-6.66); sensitivity, 0.63 (95% CI 0.50-0.74); specificity, 0.65 (95% CI 0.51-0.76); PLR, 1.83 (95% CI 1.21-2.74); NLR, 0.58 (95% CI 0.39-0.83). The SROC was 0.68.

CONCLUSION

In this current meta-analysis, the serum galactomannan test was classified as less accurate for purposes of diagnosing confirmed AIAS. These results suggest that the initial diagnosis of AIAS should not solely be dependent upon serum galactomannan test results. More studies of the test are needed in patients with AIAS to more accurately assess its diagnostic value.

The importance of mucormycosis infections on example of Rhino Orbital Cerebral Mucormycosis

Mucormycosis is an angioinvasive fungal infection, characterized by high morbidity and mortality and is strongly dependent on the patient’s general health condition, initial site of infection, and the time from diagnosis to treatment commencement. It has been reported that the occurrence of mucormycosis has increased rapidly, also among immunocompetent patients. Moreover, the rise in number is expected to continue. Among all clinical manifestations of mucormycosis, the rhino-orbital-cerebral type (ROCM) is the most common. The aim of this article is to increase the awareness of mucoral infections, especially ROCM, and to describe its first symptoms, as proper treatment requires immediate surgical and medical intervention.

Acute invasive fungal rhinosinusitis in pediatric patients with oncohematological diseases

Introduction

Invasive fungal diseases represent important causes of morbidity and mortality among pediatric oncohematological patients. Acute invasive fungal rhinosinusitis is a rare and aggressive disease that occurs mainly in immunocompromised patients. The mortality rate is high and therefore, accurate and early diagnosis is essential.

Objectives

The aim of this study was to describe the frequency of acute invasive fungal rhinosinusitis among pediatric oncohematological patients and characterize them with confirmed diagnoses.

Methods

This was a retrospective study that analyzed the medical records of pediatric patients diagnosed with oncohematological diseases and suspected fungal infections, who were included after obtaining informed consent, from January to December 2017, in the pediatric unit of a tertiary university hospital. Data collected from medical record analysis included the following: underlying diagnosis, absolute neutrophil count, clinical presentation, culture and biopsy results, surgical procedures performed, survival and mortality.

Results

A total of 27 patients were evaluated, with three suspected cases of acute invasive fungal rhinosinusitis. Histopathological and microbiological analyses confirmed two cases. In both cases, the pathogen isolated in the culture was Fusarium sp. The two confirmed cases were female, aged 12 and 14 years, both with an absolute neutrophil count of 10 cells/μL. The underlying disease of the first patient was acute myeloid leukemia (subtype M5), whereas the second patient presented idiopathic bone marrow aplasia.

Conclusion

Both confirmed cases of acute invasive fungal rhinosinusitis presented with constitutional symptoms and signs of nasal and sinusital inflammation. This demonstrates the importance of fever as a symptom in immunocompromised patients and it should prompt otorhinolaryngological investigation.

A case of rhinocerebral mucormycosis with brain abscess drained by endoscopic endonasal skull base surgery

A 70-year-old Japanese man undergoing remission induction therapy for acute monocytic leukemia (AML-M5b) developed fever and headache, and was started on antibiotics and liposomal amphotericin B (L-AMB). There was no improvement, and computed tomography and contrast-enhanced magnetic resonance imaging revealed acute rhinosinusitis and brain abscess. Successful endoscopic endonasal surgery was performed at this point, providing drainage for the rhinosinusitis and abscess. Histopathological findings showed the mucormycosis.

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

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

A model for classification of invasive fungal rhinosinusitis by computed tomography

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

Utility of Pre-Hematopoietic Cell Transplantation Sinus CT Screening in Children and Adolescents

BACKGROUND AND PURPOSE

The clinical benefit of pre-hematopoietic cell transplantation sinus CT screening remains uncertain, while the risks of CT radiation and anesthesia are increasingly evident. We sought to re-assess the impact of screening sinus CT on pretransplantation patient management and prediction of posttransplantation invasive fungal rhinosinusitis.

MATERIALS AND METHODS

Pretransplantation noncontrast screening sinus CTs for 100 consecutive patients (mean age, 11.9 ± 5.5 years) were graded for mucosal thickening (Lund-Mackay score) and for signs of noninvasive or invasive fungal rhinosinusitis (sinus calcification, hyperattenuation, bone destruction, extrasinus inflammation, and nasal mucosal ulceration). Posttransplantation sinus CTs performed for sinus-related symptoms were similarly graded. Associations of Lund-Mackay scores, clinical assessments, changes in pretransplantation clinical management (additional antibiotic or fungal therapy, sinonasal surgery, delayed transplantation), and subsequent development of sinus-related symptoms or invasive fungal rhinosinusitis were tested (exact Wilcoxon rank sums, Fisher exact test, significance P < .05).

RESULTS

Mean pretransplantation screening Lund-Mackay scores (n = 100) were greater in patients with clinical symptoms (8.07 ± 6.00 versus 2.48 ± 3.51, P < .001) but were not associated with pretransplantation management changes and did not predict posttransplantation sinus symptoms (n = 21, P = .47) or invasive fungal rhinosinusitis symptoms (n = 2, P = .59).

CONCLUSIONS

Pre-hematopoietic cell transplantation sinus CT does not meaningfully contribute to pretransplantation patient management or prediction of posttransplantation sinus disease, including invasive fungal rhinosinusitis, in children. The risks associated with CT radiation and possible anesthesia are not warranted in this setting.

Avoiding repeated surgery in patients with acute invasive fungal sinusitis

PURPOSE

We aimed to ascertain whether using an aggressive initial surgical protocol would reduce the need for repeated sinus surgery in patients with acute invasive fungal sinusitis (AIFS).

METHODS

Patients with AIFS prospectively underwent clinicoradiological assessment followed by bilateral functional endoscopic sinus surgery (FESS) and debridement of affected tissue. Antifungal therapy was also administered. Postoperative endoscopic debridement of crusts was performed weekly in the clinic. Outcomes were compared with a historical control group who underwent multiple surgeries.

RESULTS

There were 42 male and 9 female patients aged 9-68 years (mean: 42.5 years). Forty (78.4%) patients were diabetic and 17.6% had hematological malignancies. The majority (60.8%) had stage 2 or 3 disease. Partial/total maxillectomy (29.4%), orbital exenteration (7.8%) and craniotomy (2%) were also performed at a single session in 20 patients. Intra-operative sampling of all sinuses was performed. Six patients who appeared to have unilateral disease based on clinicoradiological assessment were found to have bilateral disease. Only 2 patients required revision surgery. Follow-up ranged from 3 to 24 months. The survival rate was 68.2% overall and 73.5% for diabetics alone. The difference in outcomes with a single surgery versus multiple surgeries was not significant (p = 0.09) CONCLUSION: A surgical protocol involving bilateral FESS along with debridement of visibly affected areas and antifungal therapy avoids repeated surgery in patients with AIFS with no change in outcomes. The absence of clinicoradiological involvement of the paranasal sinuses does not preclude the presence of invasive fungal disease in these sinuses.

Benefit of Endoscopic Surgery in the Management of Acute Invasive Skull Base Fungal Rhinosinusitis

Objective  This article aims to characterize 14 patients who underwent purely endoscopic surgical debridement of acute invasive skull base fungal rhinosinusitis, and to evaluate postoperative outcomes and risk for recurrence. Design  Retrospective cohort study. Setting  Tertiary single-institution neurosurgery department. Participants  We performed a retrospective analysis of all patients with skull base fungal infections treated with a purely endoscopic surgical approach at Mount Sinai Hospital from 1998 to 2018. Main Outcome Measures  Clinical presentation, number of recurrences, and mortality rate. Results  The most common underlying medical comorbidities were hematologic malignancy in 8 (57.1%) patients and poorly controlled diabetes mellitus in 7 (50%) patients. Presenting symptoms included headache (50%), eye pain (35.7%), facial pain (28.6%), visual changes (21.4%), and nasal congestion (14.3%). The fungal organisms identified on culture were Aspergillus (42.9%), Mucorales (28.6%), Fusarium (14.3%), Penicillium (7.1%), and unspecified (7.1%). Eight (57.1%) patients developed recurrence and required multiple surgical debridements. Patients who had only a hematologic malignancy were more likely to require multiple surgical debridements compared with those who did not have a hematologic malignancy or those who had both hematologic malignancy and underlying diabetes mellitus ( p  = 0.03). The mortality rate from surgery was 42.9%. Conclusion  Surgical endoscopic intervention is an option for definitive management of acute invasive skull base fungal rhinosinusitis; however, postoperative mortality and risk of recurrence requiring additional surgical interventions remains high. Patients with hematologic malignancy may be more susceptible to recurrent infection requiring multiple surgical debridements. We recommend early aggressive multimodal treatment. Multiple debridements may be warranted in most cases; close clinical surveillance is needed during neurosurgical intervention.

Diagnosis and Treatment of Acute Invasive Fungal Sinusitis in Cancer and Transplant Patients

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.

Invasive Cryptococcal Meningitis Presenting as a Skull Base Mass in An Immunocompetent Host: A Case Report

Introduction  Encephalitis due to Cryptococcus neoformans has been seen almost exclusively in patients with severe compromise of their immune systems, such as acquired immune deficiency syndrome (AIDS). Fungal sinusitis with frank invasion through the cranial base and subsequent seeding of the central nervous system is rare, but should be considered in the differential of patients presenting with meningitis and sinus/skull base lesions even without obvious immune compromise. Improvements in diagnostic testing has increased the ability to correctly identify and new antimicrobials have allowed a condition that once carried a high morbidity and mortality to be managed with better outcomes. We present our treatment algorithm for successful management of an immunocompetent patient with extensive fungal encephalitis due to erosion through the skull base.

Case Description  The patient is a 59-year-old male presenting unresponsive with sphenoid mass erosive of the skull base and symptoms of meningitis and encephalitis due to C. neoformans . Magnetic resonance imaging (MRI) at presentation demonstrated extensive diencephalic invasion, and a sphenoid mass with erosion of the skull base. Lumbar puncture (LP) confirmed elevated opening pressure of 45 cm H2O, and cultures confirmed infection with C. neoformans . He underwent operative sinonasal debridement followed by placement of an external ventricular drain for management of hydrocephalus. He was treated aggressively with a combination of both intravenous (IV) amphotericin B daily and intrathecal amphotericin B via the ventriculostomy thrice weekly. By the 2nd week of treatment, patient regained consciousness. After 4 weeks of therapy, cerebrospinal fluid (CSF) cultures turned negative, and the external ventricular drain (EVD) was converted to a ventriculoperitoneal shunt (VPS) to manage chronic postinfectious hydrocephalus. We also placed a contralateral Ommaya reservoir to permit continued weekly intrathecal amphotericin B without violation of the shunt valve. With each instillation, the shunt was set to its highest setting to minimize CSF egress for 6 hours then reset to its “drainage” setting. After an additional 6 weeks of outpatient therapy, intrathecal therapy was discontinued. We continued CSF surveillance via Ommaya sampling monthly. At 9-month follow-up, he has remained clinically stable without evidence of recurrent infection. He has residual mild cognitive deficits, but is living semiindependently with his brother.

Conclusions  Fungal sinusitis is uncommon, especially in those without significantly compromised immune systems. Invasive fungal meningitis resulting in meningitis and encephalitis is even rarer. The condition carries high morbidity and mortality that can only be mitigated with a multidisciplinary effort by neurosurgery, otolaryngology, and infectious disease specialists. While there are no clear treatment guidelines, we present an approach that may permit longer term independent survival.

Mucormycosis of the Central Nervous System

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.

Acute invasive fungal rhinosinusitis: our 2 year experience and outcome analysis

PURPOSE

The incidence of Acute invasive fungal rhinosinusitis (AIFRS) is on the rise considering the multitude of comorbidities present in a single patient.The delay in suspecting the fungal etiology, presentation of the patient for an Otorhinolaryngology consult and lack of defined protocols affects outcome.This study looks in to the various aspects of treatment of AIFRS including sample collection, diagnosis and medicosurgical treatment. We propose a protocol for the management of these patients crafted from our outcome.

METHODS

Between September 2015-September 2017, 14 patients presented with AIFRS. Targeted samples were taken for Potassium hydroxide mount, histopathological studies and fungal culture. Management was initiated with antifungals and multi-approach surgical debridement.

RESULTS

Six of these patients had multiple comorbidities and most were uncontrolled diabetics. The average delay in presentation was 9 days. Potassium hydroxide mount was the screening test of choice. A minimum of two sittings of debridement was essential. In an average follow-up period of 15.12 months, all the patients are alive and disease free.

CONCLUSION

A high index of suspicion, awareness among medical fraternity and precise sample collection aids a firm diagnosis. Simultaneous initiation of surgical debridement and anti-fungals is fundamental.

Inpatient Mortality After Endoscopic Sinus Surgery for Invasive Fungal Rhinosinusitis

OBJECTIVES:

Invasive fungal rhinosinusitis is a rare, life-threatening condition that affects the paranasal sinuses. The standard of care after diagnosis includes surgical debridement and aggressive medical management. Despite treatment, mortality remains unacceptably high. Most data are derived from small cohort experiences, with limited identification of mortality risk factors in the acute setting. The authors used a large national database to better understand clinical factors associated with inpatient mortality for this challenging condition.

METHODS:

Using the 2000-2014 National (Nationwide) Inpatient Sample database, the authors identified 979 adult patients with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of mucormycosis or aspergillosis and a procedure code of sinus surgery. Multivariate imputation by chained equation was performed to account for missing data, followed by multivariate logistic regression to identify predictors of inpatient mortality.

RESULTS:

In total, 979 adult patients were identified, with a median age of 57 years. The inpatient mortality rate was 15.8%. The most prevalent comorbidity was hematologic disorders (42.9%). Mucormycosis versus aspergillosis was associated with increased odds of inpatient mortality (odds ratio, 2.95; 95% confidence interval, 2.00-4.34; P < .001). The odds of inpatient mortality were significantly increased between patients with hematologic disorders and those without (odds ratio, 1.92; 95% confidence interval, 1.08-3.39; P = .024). Diabetes (odds ratio, 0.53; 95% confidence interval, 0.34 - 0.80; P = .003) was associated with the lowest odds of inpatient mortality.

CONCLUSIONS:

This represents the first population-based study evaluating the factors associated with inpatient mortality. These findings support prior observations demonstrating that the underlying immune dysfunction and type of fungal infection are important predictors of early mortality.

Therapy of Mucormycosis

Despite the recent introduction of mold-active agents (posaconazole and isavuconazole), in addition to amphotericin B products, to our armamentarium against mucormycosis, many uncertainties remain for the management of this uncommon opportunistic infection, as there are no data from prospective randomized clinical trials to guide therapy. In this mini-review, we present the current status of treatment options. In view of the heterogeneity of the disease (different types of affected hosts, sites of infection, and infecting Mucorales), mucormycosis management requires an individualized management plan that takes into account the net state of immunosuppression of the host, including comorbidities, certainty of diagnosis, site of infection, and antifungal pharmacological properties.

Diabetes mellitus as the major risk factor for mucormycosis in Mexico: Epidemiology, diagnosis, and outcomes of reported cases

Mucormycosis is an emerging infectious disease with high rates of associated mortality and morbidity. Little is known about the characteristics of mucormycosis or entomophthoromycosis occurring in Mexico. A search strategy was performed of literature published in journals found in available databases and theses published online at Universidad Nacional Autónoma de México (UNAM) library website reporting clinical cases or clinical case series of mucormycosis and entomophthoromycosis occurring in Mexico between 1982 and 2016. Among the 418 cases identified, 72% were diabetic patients, and sinusitis accounted for 75% of the reported cases. Diabetes mellitus was not a risk factor for entomophthoromycosis. Mortality rate was 51% (125/244). Rhizopus species were the most frequent isolates (59%, 148/250). Amphotericin B deoxycholate was used in 89% of cases (204/227), while surgery and antifungal management as combined treatment was used in 90% (172/191). In diabetic individuals, this combined treatment approach was associated with a higher probability of survival (95% vs 66%, OR = 0.1, 95% CI, 0.02-0.43' P = .002). The most common complications were associated with nephrotoxicity and prolonged hospitalization due to IV antifungal therapy. An algorithm is proposed to establish an early diagnosis of rhino-orbital cerebral (ROC) mucormycosis based on standardized identification of warning signs and symptoms and performing an early direct microbiological exam and histopathological identification through a multidisciplinary medical and surgical team. In summary, diabetes mellitus was the most common risk factor for mucormycosis in Mexico; combined antifungal therapy and surgery in ROC mucormycosis significantly improved survival.

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

INTRODUCTION

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

CASE PRESENTATION

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

DISCUSSION

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

Fungal Rhinosinusitis: A Radiological Review with Intraoperative Correlation

The interaction between fungi and the sinonasal tract results in a range of clinical presentations with a broad spectrum of clinical severity. The most commonly accepted classification system divides fungal rhinosinusitis into invasive and noninvasive subtypes based on histopathological evidence of tissue invasion by fungi. Invasive fungal rhinosinusitis is subdivided into acute invasive and chronic invasive categories. The chronic invasive category includes a subcategory of chronic granulomatous disease. Noninvasive fungal disease includes localized fungal colonization, fungal ball, and allergic fungal rhinosinusitis. Noninvasive disease is simply fungal material (or the products of the inflammatory reaction of the sinus mucosa) that fills the sinuses but does not invade tissue. Bone loss is related to expansion of the sinus(es). Invasive disease causes tissue destruction, such that it expands past the bony confines of the sinuses. It can rapidly spread, causing acute necrosis. Alternatively, there may be slow tissue invasion characterized by symptoms confused with normal sinusitis, but destruction of normal nasal and paranasal structures.

Advanced surgical technique for invasive fungal sinusitis: endoscopic orbit-sinus combined approach

BACKGROUND

Invasive fungal sinusitis is usually associated with poor prognosis, but no clear guidelines have been established for surgical treatment. Here, we report the development and application of the endoscopic orbit-sinus combined approach (EOSCA), a novel surgical technique to approach the nasal cavity and orbit concurrently, in patients with invasive fungal sinusitis with orbital infiltration.

MATERIAL AND METHODS

Two patients with invasive fungal sinusitis infiltrating the orbit underwent EOSCA. Transnasal endoscopy was performed for maximum debulking of tissues infiltrated by fungi in the nasal cavity and orbit, before making an incision into the palpebral conjunctiva. An endoscope was then inserted into the orbit through the incision in the palpebral conjunctiva to remove adipose tissue and muscles that had been infiltrated by fungi from the orbital regions where the transnasal approach was difficult or impossible. Another surgeon assisted the procedure by operating an endoscope concurrently via the nasal cavity (four-hands technique).

RESULTS

We were able to remove lesions safely and with precision, preserving visual acuity and a functional eyeball in both cases. Currently, the patients are alive, with no postoperative complications, recurrence, or disfigurement.

CONCLUSIONS

This novel method shows promise as a safe and reliable surgical procedure for patients with invasive fungal sinusitis infiltrating into the orbit, with no postoperative complications, recurrence, or disfigurement.

Acute Rhinosinusitis in Immunosuppressed Children: Diagnostic and Therapeutic Management

BACKGROUND

Immunosuppressive therapy places pediatric patients at risk of developing life-threatening sinonasal infections. Diagnosis and treatment are challenging owing to nonspecific signs and symptoms. The aim of this study was to present our department's experience with the surgical management of acute rhinosinusitis in immunosuppressed children.

METHODS

The records of all children with a hematologic or oncologic disease who underwent endoscopic sinus surgery (ESS) for acute rhinosinusitis from January 2005 to May 2014 were reviewed. Data were retrospectively collected on demographics, clinical and imaging characteristics, microbiology, pathology, treatment and outcome.

RESULTS

Thirty-four-immunosuppressed children underwent ESS for acute rhinosinusitis. Most patients had a fungal infection. Nineteen patients died at the end of follow-up; 10 deaths were infection-related. Facial swelling was the only symptom that correlated with death of infection. Relapse of the underlying disease, bone marrow transplantation, and long duration of neutropenia correlated with infection-related mortality. Fungal infection, and specifically Aspergillus, correlated with death from infection.

CONCLUSIONS

ESS is a safe and efficient procedure for diagnosing and treating immunosuppressed pediatric patients with acute rhinosinusitis. Early detection and aggressive medical and surgical treatment, with control of underlying risk factors, are crucial to improve outcome.

Acute invasive fungal rhinosinusitis: Survival analysis and the prognostic indicators

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Successful Isavuconazole therapy in a patient with acute invasive fungal rhinosinusitis and acquired immune deficiency syndrome

OBJECTIVES

To report a case of acute invasive Mucorales rhinosinusitis in a patient with acquired immune deficiency syndrome and diabetes mellitus. To provide a literature review on the role of Isavuconazole in the management of invasive Mucorales rhinosinusitis.

METHODS

A literature review was conducted on August 9, 2015 using PubMed database. The keywords isavuconazole and invasive fungal rhinosinusitis were employed to identify original scientific manuscripts that describe the use of Isavuconazole in patients with invasive fungal rhinosinusitis or rhinocerebral mucormycosis.

RESULTS

The initial search yielded 35 articles with only 1 article (case report) describing the clinical use of Isavuconazole in a patient with invasive Mucorales rhinosinusitis.

CONCLUSIONS

Acute invasive fungal rhinosinusitis is a rare, life-threatening infection with mortality rates reported to range from 30-83%. Successful treatment depends on early surgical debridement, systemic anti-fungal therapy, and correction of predisposing conditions. Isavuconazole (Cresemba), a newly approved antifungal, is safe and clinically effective in treating invasive mucormycosis. This important new therapy should be considered for patients with invasive Mucorales rhinosinusitis that is refractory or intolerant to Amphotericin B.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Acute Invasive Fungal Rhinosinusitis: A Comprehensive Update of CT Findings and Design of an Effective Diagnostic Imaging Model

BACKGROUND AND PURPOSE

Acute invasive fungal rhinosinusitis carries a high mortality rate. An easy-to-use and accurate predictive imaging model is currently lacking. We assessed the performance of various CT findings for the identification of acute invasive fungal rhinosinusitis and synthesized a simple and robust diagnostic model to serve as an easily applicable screening tool for at-risk patients.

MATERIALS AND METHODS

Two blinded neuroradiologists retrospectively graded 23 prespecified imaging abnormalities in the craniofacial region on craniofacial CT examinations from 42 patients with pathology-proven acute invasive fungal rhinosinusitis and 42 control patients proved negative for acute invasive fungal rhinosinusitis from the same high-risk population. A third blinded neuroradiologist decided discrepancies. Specificity, sensitivity, positive predictive value, and negative predictive value were determined for all individual variables. The 23 variables were evaluated for intercorrelations and univariate correlations and were interrogated by using stepwise linear regression.

RESULTS

Given the low predictive value of any individual variable, a 7-variable model (periantral fat, bone dehiscence, orbital invasion, septal ulceration, pterygopalatine fossa, nasolacrimal duct, and lacrimal sac) was synthesized on the basis of multivariate analysis. The presence of abnormality involving a single variable in the model has an 87% positive predictive value, 95% negative predictive value, 95% sensitivity, and 86% specificity (R(2) = 0.661). A positive outcome in any 2 of the model variables predicted acute invasive fungal rhinosinusitis with 100% specificity and 100% positive predictive value.

CONCLUSIONS

Our 7-variable CT-based model provides an easily applicable and robust screening tool to triage patients at risk for acute invasive fungal rhinosinusitis into a disease-positive or -negative category with a high degree of confidence.

Fungal rhinosinusitis: what every allergist should know

The interaction between fungi and the sinonasal tract results in a diverse range of diseases with an equally broad spectrum of clinical severity. The classification of these interactions has become complex, and this review seeks to rationalize and simplify the approach to fungal diseases of the nose and paranasal sinuses. These conditions may be discussed under two major headings: non-invasive disease (localized fungal colonization, fungal ball and allergic fungal rhinosinusitis) and invasive disease (acute invasive rhinosinusitis, chronic invasive rhinosinusitis and granulomatous invasive rhinosinusitis). A diagnosis of fungal rhinosinusitis is established by combining findings on history, clinical examination, laboratory testing, imaging and histopathology. The immunocompetence of the patient is of great importance, as invasive fungal rhinosinusitis is uncommon in immunocompetent patients. With the exception of localized fungal colonization, treatment of all forms of fungal rhinosinusitis relies heavily on surgery. Systemic antifungal agents are a fundamental component in the treatment of invasive forms, but are not indicated for the treatment of the non-invasive forms. Antifungal drugs may have a role as adjuvant therapy in allergic fungal rhinosinusitis, but evidence is poor to support recommendations. Randomized controlled trials need to be performed to confirm the benefit of immunotherapy in the treatment of allergic fungal rhinosinusitis. In this article, we will summarize the current literature, addressing the controversies regarding the diagnosis and management of fungal rhinosinusitis, and focussing on those aspects which are important for clinical immunologists and allergists.

A Novel Model of Invasive Fungal Rhinosinusitis in Rats

Background

Invasive fungal rhinosinusitis (IFRS) is a life-threatening inflammatory disease that affects immunocompromised patients, but animal models of the disease are scarce. This study aimed to develop an IFRS model in neutropenic rats.

Methods

The model was established in three consecutive steps: unilateral nasal obstruction with Merocel sponges, followed by administration of cyclophosphamide (CPA), and, finally, nasal inoculation with Aspergillus fumigatus. Fifty healthy Wistar rats were randomly divided into five groups, with group I as the controls, group II undergoing unilateral nasal obstruction alone, group III undergoing nasal obstruction with fungal inoculation, group IV undergoing nasal obstruction with administration of CPA, and group V undergoing nasal obstruction with administration of CPA and fungal inoculation. Hematology, histology, and mycology investigations were performed.

Results

The changes in the rat absolute neutrophil counts (ANCs) were statistically different across the groups. The administration of CPA decreased the ANCs, whereas nasal obstruction with fungal inoculation increased the ANCs, and nasal obstruction did not change them. Histological examination of the rats in group V revealed the hyphal invasion of sinus mucosa and bone, thrombosis, and tissue infarction. No pathology indicative of IFRS was observed in the remaining groups. Positive rates of fungal culture in tissue homogenates from the maxillary sinus (62.5%) and lung (25%) were found in group V, whereas groups I, II, III, and IV showed no fungal culture in the homogenates.

Conclusion

A rat IFRS model was successfully developed through nasal obstruction, CPA-induced neutropenia, and fungal inoculation. The disease model closely mimics the pathophysiology of anthropic IFRS.