Fungal rhinosinusitis and imaging modalities

Infectious optic neuropathy (ION), how to recognise it and manage it

Optic neuropathy can be of infectious or non-infectious/idiopathic aetiology. Many infectious organisms can cause optic neuropathy that can be of varied presentation including papillitis, retrobulbar optic neuritis, neuroretinitis, and optic perineuritis. Detailed history, ocular, systemic/neurologic examination along with appropriate laboratory evaluation can help clinicians to identify the infectious agent causing optic neuropathy. In spite of recent advanced techniques in serological testing and molecular diagnostics like polymerase chain reaction (PCR), the identification of these pathogens is still a diagnostic challenge. It is ideal to have an infectious disease (ID) consultant in the management team, as most of these infections are multisystem involving diseases. Most infectious agents can be effectively treated with specific antibiotics, with or without corticosteroid therapy, but visual recovery is highly variable and depends entirely on early diagnosis of the causative agent. This review article will provide an overview of common pathogens involved in ION and will describe their management paradigms.

Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study

PURPOSE

To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM).

METHODS

In this retrospective case-control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (-TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality.

RESULTS

Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality.

CONCLUSIONS

Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

Imaging Findings in Aspergillosis: From Head to Toe

Aspergillosis is a mycotic infection induced by airborne fungi that are ubiquitous. Inhalation of Aspergillus conidia results in transmission through the respiratory tract. The clinical presentation is dependent on organism and host specifics, with immunodeficiency, allergies, and preexisting pulmonary disease constituting the most important risk factors. In recent decades, the incidence of fungal infections has increased dramatically, due in part to the increased number of transplants and the pervasive use of chemotherapy and immunosuppressive drugs. The spectrum of clinical manifestations can range from an asymptomatic or mild infection to a swiftly progressive, life-threatening illness. Additionally, invasive infections can migrate to extrapulmonary sites, causing infections in distant organs. Recognition and familiarity with the various radiological findings in the appropriate clinical context are essential for patient management and the prompt initiation of life-saving treatment. We discuss the radiological characteristics of chronic and invasive pulmonary aspergillosis, as well as some of the typically unexpected extrapulmonary manifestations of disseminated disease.

Allergic Fungal Rhinosinusitis in Europe: Literature Review and Own Experience

Allergic fungal rhinosinusitis (AFRS) is primary, Th2-mediated, chronic rhinosinusitis, which is diagnosed when the criteria defined by Bent and Khun are met. The disease is most common in countries located in the subtropical and tropical regions characterized by high temperatures and high levels of humidity, which favour the wider occurrence of fungi in the environment. The presence of specific IgE antibodies directed against fungal allergens, which is one of the diagnostic criteria, proves the systemic nature of the disease and allows one to distinguish AFRS from eosinophilic fungal rhinosinusitis. There is no unified treatment method for AFRS described in the literature, and relapses are common. Sinus surgery remains the treatment of choice. Oral and topical steroid therapy plays an important role in the treatment process. The effectiveness of antifungal treatment and immunotherapy is unclear. Biological treatment, the results of which are promising, has raised great hopes. The aim of this study was to reveal how often AFRS occurs in European countries, what environmental factors influence its development, and how important it is to specify its diagnostic criteria and treatment methods. We present an overview of the available literature. In addition, we share our own experience and describe two cases of AFRS diagnosed and treated at our centre.

Transcaruncular medial orbitotomy: A globe sparing intervention in management of COVID associated mucormycosis [CAM]

AIMS

To describe a novel method of transcaruncular medial orbitotomy, local debridement and amphotericin B irrigation into orbit for COVID-19-associated rhino-orbital mucormycosis. Also to evaluate its its outcome in controlling the disease, increasing the survival rate and as a globe-sparing intervention in them.

METHODOLOGY

A total of ten COVID-19-associated mucormycosis patients with clinical and radiological evidence of orbital involvement with necrotic tissue localized in medial orbit were considered for our study. A transcaruncular modified medial orbitotomy with medial and inferomedial orbit debridement was done along with placement of scalp vein catheter by a single surgeon. Postoperatively 3.5 mg/ml liposomal amphotericin B irrigation through the catheter was done for 5 sittings. Correction of underlying systemic conditions and intravenous antifungals were given. Clinical response to the procedure was noted on postoperative week 1, week 4, and 3rd month (week 12).

RESULTS

The mean age group was noted to be 49.9 years with a male: female ratio of 2.3:1. All patients were diabetics with 5 being newly detected diabetes after COVID infection. All the ten patients showed significant clinical improvement at the first follow-up (week 1). Five patients at 1st month showed clinical and radiological improvement, while one patient had worsening of orbital disease for which exenteration was done. Three patients succumbed to the disease due to altered cardiopulmonary status and 1 patient was lost to follow-up. All 6 survived patients were stable till the last follow-up. Hence, mortality rate accounted to 30% and globe survival of 40% in the current study.

CONCLUSION

Transcaruncular approach to orbit for adequate debridement combined with amphotericin irrigation is a novel technique that can be considered for compartmental involvement of orbit in mucormycosis. Debridement removes the necrotic tissue, while local amphotericin irrigation directly reaches the target tissues that effectively halts the disease progression and hence can be considered an effective globe-sparing intervention without affecting the disease outcome.

Magnetic Resonance Imaging Features of Rhino-Orbito-Cerebral Mucormycosis in Post-COVID-19 Patients: Radio-Pathological Correlation

There has been a notable increase in rhino-orbito-cerebral mucormycosis (ROCM) post-coronavirus disease 2019 (COVID-19), which is an invasive fungal infection with a fatal outcome. Magnetic resonance imaging (MRI) is a valuable tool for early diagnosis of ROCM and assists in the proper management of these cases. This study aimed to describe the characteristic MRI findings of ROCM in post-COVID-19 patients to help in the early diagnosis and management of these patients. This retrospective descriptive study was conducted at a single hospital and included 52 patients with COVID-19 and a histopathologically proven ROCM infection who were referred for an MRI of the paranasal sinuses (PNS) due to sino-orbital manifestations. Two radiologists reviewed all the MR images in consensus. The diagnosis was confirmed by histopathological examination. The maxillary sinus was the most commonly affected PNS (96.2%). In most patients (57.7%), multiple sinuses were involved with the black turbinate sign on postcontrast images. Extrasinus was evident in 43 patients with orbital involvement. The pterygopalatine fossa was involved in four patients. Three patients had cavernous sinus extension, two had pachymeningeal enhancement, and one had epidural collection. The alveolar margin was affected in two patients, and five patients had an extension to the cheek. The awareness of radiologists by the characteristic MRI features of ROCM in post-COVID-19 patients helps in early detection, early proper management, and prevention of morbid complications.

Magnetic Resonance Imaging Prognostic Findings for Visual and Mortality Outcomes in Acute Invasive Fungal Rhinosinusitis

PURPOSE

To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020.

METHODS

A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality.

MAIN OUTCOME MEASURE

Identification of initial, preintervention MRI findings associated with visual and mortality outcomes.

RESULTS

The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; P < 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001).

CONCLUSIONS

Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality.

Retrobulbar Injection of Amphotericin B in Patients With COVID-19 Associated Orbital Mucormycosis: A Systematic Review

PURPOSE

Following COVID-19 infection a rising count of rhino-orbito-cerebral mucormycosis is observed, requiring orbital exenteration, a disabling lifetime affecting surgery. One of the potential interventions for globe salvage in these patients is retrobulbar injections of amphotericin B. This study was conducted to review protocols, outcomes, and side effects of retrobulbar injection of amphotericin B in patients with COVID-19 associated rhino-orbito-cerebral mucormycosis (CAM).

METHODS

The PubMed, Scopus, Web of Science, and Embase databases were searched using a comprehensive string of relevant keywords. All English studies with the confirmed diagnosis of CAM infection were included. We excluded all studies in which retrobulbar injection of amphotericin B was not implemented in any of the patients or there was a lack of clarified and detailed data about this procedure among participants.

RESULTS

A total of 647 cases had a history of retrobulbar injection(s) of amphotericin B in 13 reviewed studies with 3,132 subjects of CAM. The most common protocol was the retrobulbar injection of 1 ml of 3.5 mg/ml liposomal amphotericin B for 3 doses daily or on alternate days. We discerned that the globe salvage rate was 95.0% in eyes with a history of retrobulbar injection(s). The total rate of orbital exenteration was 14.9%, regardless of the history of retrobulbar injection of the drug. Other outcomes of this intervention were vision salvage and reduced major ophthalmic complaints, including pain, swelling, chemosis, ptosis, and ophthalmoplegia. The side effects of this intervention were not serious, and most of them were transient. They included swelling at the injection site, restriction of ocular motilities, exacerbation of orbital inflammation, and even intensification of visual impairment in a few cases.

CONCLUSIONS

Retrobulbar injection of amphotericin B should be considered a nearly safe and protective intervention against orbital exenteration in patients with CAM. It may also be effective in saving vision. Since the effectiveness of orbital exenteration in the survival of patients is not ascertained, retrobulbar injections can be considered an alternative intervention.

Chronic invasive fungal sinusitis with orbital and olfactory cleft involvement secondary to indolent mucormycosis

Purpose

Chronic invasive fungal sinusitis secondary to indolent mucormycosis is a rare clinical entity, and the ideal management is controversial. A case of indolent mucormycosis successfully managed with conservative debridement and retrobulbar amphotericin B is herein reported.

Observations

A 42-year-old man with diabetes mellitus and kidney transplant presented with chronic invasive fungal sinusitis with left orbital involvement from indolent mucormycosis. The patient was treated with aggressive systemic antifungal therapy, left retrobulbar injection of liposomal amphotericin B, reduction in immunosuppression, and conservative surgical debridement. Although the left olfactory cleft was involved, the cribriform plate was not resected due to risk of seeding the intracranial space. Given mild orbital involvement, no orbital debridement was performed and the patient had resolution of his orbital findings with systemic and retrobulbar amphotericin B. The patient had clinical and radiographic stability at 6-month follow-up.

Conclusions

Conservative resection with subsequent long-term antifungal treatment can be a successful regimen in indolent mucormycosis. Retrobulbar amphotericin B may be a prudent orbit-sparing adjuvant therapy in indolent mucormycosis.

Post COVID-19 Head and Neck Mucormycosis: MR Imaging Spectrum and Staging

Objective

To develop a systematic approach for magnetic resonance imaging (MRI) analysis, imaging spectrum, and classification system for the staging of post-COVID-19 head and neck mucormycosis.

Method

The study included 63 post-COVID-19 patients with pathologically proven mucormycosis who underwent head and neck MR imaging. Three independent radiologists assessed the imaging spectrum of mucormycosis, MRI characteristics of sino-nasal mucormycosis, and extra-sinus extension, and submitted a final staging using a systematic approach and a proposed categorization system. A consensus reading was considered the reference imaging standard. The kappa statistics were used to assess the categorization system's diagnostic reliability.

Results

The overall interreader agreement of the MR staging system was very good (k-score = 0.817). MR imaging spectrum involved localized sino-nasal mucormycosis (n = 7 patients, 11.1%), sino-nasal mucormycosis with maxillo-facial soft tissue extension (n = 28 patients, 44.5 %), sino-nasal mucormycosis with maxillo-facial bony extension (n = 7 patients, 11.1%), sino-naso-orbital mucormycosis (n = 13 patients, 20.6%), and sino-nasal mucormycosis with cranium or intracranial extension (n = 8 patients, 12.7%). Extra-sinus extension to the orbit and brain did not have significant association with involvement of the posterior ethmoid/sphenoid sinuses and maxillo-facial regions (p > 0.05). MRI-based staging involved four stages: stage 1 (n = 7, 11.1%); stage 2 (n = 35, 55.6%), and stage 3 (n = 13, 20.6%), and stage 4 (n = 8, 12.7%). Involvement of the bone and MR-based staging were significant predictors of patients’ mortality p = 0.012 and 0.033, respectively.

Conclusion

This study used a diagnostic-reliable staging method to define the imaging spectrum of post-COVID-19 head and neck mucormycosis and identify risk variables for extra-sinus extension.

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.

The nonlinear association between albumin levels and risk of noninvasive fungal rhinosinusitis

PURPOSE

The preoperative diagnosis of noninvasive fungal rhinosinusitis (NIFRS) is inaccurate, and biomarkers to assist the diagnosis are urgently needed. We aimed to evaluate the relationship between albumin levels and NIFRS to assist in early diagnosis.

METHODS

Patients with NIFRS and chronic sinusitis were enrolled in this study. Appropriate statistical methods were used to determine whether there was a statistical difference between the groups. Subgroup analysis was performed to investigate the relationship between albumin levels and NIFRS, and a generalised additive model (GAM) was used to perform nonlinear relationships.

RESULTS

A total of 620 patients were included, including 240 patients with NIFRS. A close relationship was found between albumin levels and NIFRS (P < 0.0001), and the low albumin group was associated with a higher incidence of NIFRS, which was reduced by 60 and 70% in the middle and high albumin groups, respectively. The subgroup analysis also demonstrated an association between albumin levels and NIFRS, except in patients with an alcohol history (P = 0.0665). Interestingly, a nonlinear relationship is observed according to the adjusted GAM. The inflection point was set at 37.0 g/L. A negative correlation was observed among patients with albumin > 37.0 g/L. When the albumin count was <37.0 g/L, the Y value obviously increased and was saturated at 70%, with no further significant increase.

CONCLUSION

Albumin levels were significantly negatively correlated with the incidence of NIFRS, and the incidence increased markedly among patients with albumin < 37.0 g/L.

Magnetic resonance imaging features of post-COVID-19 regional and invasive sino-nasal mucormycosis

Background

Sino-nasal mucormycosis is an opportunistic, invasive fungal disease which has shown a rising trend in the setting of COVID-19. The objective of this study is to document and analyze demographic data, clinical presentation and MR imaging spectra for early detection and management of post-COVID-19 sino-nasal mucormycosis.

Results

Sixty-two cases of sino-nasal mucormycosis were enrolled in this study; their mean age was 50.65 ± 8.25 years, with significant female predominance. Nine patients (14.5%) had active COVID-19 and 53 (85.5%) were recent COVID-19 cases. Sixty patients have not received COVID-19 vaccine. The mean duration from the initial COVID-19 laboratory confirmation to the detection of sino-nasal mucormycosis was 25.7 +/− 4.6 days. Thirty-five patients (56.5%) were kept in the hospital for COVID management and 4 of them received intensive care unit (ICU) treatment. Twenty-seven patients (43.5%) were treated in home isolation. Corticosteroids were administered in 48 cases (77.4%). Twenty-nine patients (46.8%) had been given oxygen for an average time of 11.2 ± 4.15 days. Diabetes was found in 56 cases (90.3%). The most common clinical symptoms were headache, seen in 52 patients (83.87%). The ethmoid sinus was the most common paranasal sinus involved in our study, seen in 47 cases (75.81%). In 36 cases (58%), multiple sinuses were involved. MRI staging according to the extent of regional involvement. Stage 1 seen in 2 cases (3.23%), stage 2 in 13 cases (20.97%), stage 3 in 35 cases (56.45%) and stage 4 in 12 cases (19.35%).

Conclusions

MRI shows a spectrum of findings in sino-nasal mucormycosis. Imaging plays a major role in staging and assessing the extent of involvement and complications. In light of this, mortality and morbidity can be dramatically decreased with adequate evaluation and therapy.

MRI as a road-map for surgical intervention of acute invasive fungal sinusitis in Covid-19 era

OBJECTIVES

Acute invasive fungal sinusitis AIFS has high mortality rate, and its incidence has increased without explanation in Covid-19 era. Proper diagnosis and effective surgical debridement have a crucial role in decreasing this high mortality rate. MRI could detect early ischemic changes with localization of extrasinus devitalized fungal inflamed tissue to guide surgical intervention.

STUDY DESIGN

Prospective study SETTING: ORL-HNS department -Zagazig University.

METHODS

T1 with gadolinium and T2 fat suppression sequences were investigated and correlated with surgical findings in cases recently recovered from Covid-19 "seroconversion". Loss of contrast enhancement LOCE/black sign in T1+G was hypothesized to reflect necrotic areas while hyperintense signal/white sign in T2 fat suppression was hypothesized to correlate with severely inflamed devitalized tissue in periantral region These radiological findings were correlated with intraoperative findings to identify positive predictive finding.

RESULTS

40 patients were included in this study, of which 38 had LOCE/ black sign in T1+G 95%. True ischemic turbinate was detected only in 35 cases (positive predictable value PPV= 92.1%). Hyperintense signal/ white sign in T2 fat suppression was detected in orbit, pterygopalatine-infratemporal fossa, sphenoid process, zygoma, external skin, and these findings were correlated with intraoperative findings (PPV ranging from 72.7% to 100%).

CONCLUSION

MRI has a crucial role in localization of devitalized tissue, and subsequently guides surgical intervention.

Revisiting rhino-orbito-cerebral acute invasive fungal sinusitis in the era of COVID-19: pictorial review

COVID-19 patients have been found to have an increased incidence of superadded fungal infections because of multiple factors such as impaired cell-mediated immunity, immunosuppressive therapy, and coexistent diabetes mellitus. Recently, there has been a significant rise in the COVID-19-associated mucormycosis and aspergillosis cases involving the sinonasal cavity and the lungs. Rhino-orbito-cerebral acute invasive fungal rhinosinusitis (AIFR) is a potentially life-threatening, invasive fungal infection. Early diagnosis followed by prompt medical management and surgical intervention is crucial for patient survival. The role of cross-sectional imaging (CT/MRI) is not only to suggest a diagnosis of invasive fungal sinusitis but also to delineate the complete extent of disease. Mapping the extent of orbital and intracranial disease has prognostic as well as management implications, as involvement of these sites marks a worse prognosis. A stepwise approach to evaluation of imaging of AIFR along with a pictorial depiction of the key imaging findings is presented.

Imaging findings using a combined MRI/CT protocol to identify the "entire iceberg" in post-COVID-19 mucormycosis presenting clinically as only "the tip"

AIM

To analyse combined computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of invasive rhino-orbital mucormycosis (IROM) in post-COVID-19 infection patients for accurate diagnosis and delineation of the extent of involvement.

MATERIALS AND METHODS

A retrospective analysis was undertaken of 50 patients who developed IROM post-COVID-19 infection who underwent combined CT/MRI evaluation.

RESULTS

The age range of the 50 affected patients was 23-73 years. Out of these, 41 were diabetic. CT/MRI showed predominant involvement of the maxillary (n=26) and ethmoid (n=19) sinuses. Extension of disease to the orbit (n=35), cavernous sinus (n=18), hard palate (n=15), skull base (n=8), and intracranial involvement (n=3) was seen. Perineural spread of the disease was analysed along all divisions of the trigeminal nerve and its branches. MRI showed T2-hypointense soft-tissue thickening with heterogeneous contrast enhancement with corresponding hyperdensities on CT diagnosing the presence of fungal elements.

CONCLUSION

Clinicians should be aware of the possibility of IROM post-COVID-19 infection. Conjunctive use of CT, which depicts bone destruction and other reactive bony changes along with MRI, which reveals characteristic findings of soft-tissue thickening of the involved sinuses with extension of disease to the orbits, cavernous sinus, dura, hard palate, skull base, and intracranial structures. Accurate diagnosis and early recognition of the disease and its extension with appropriate use of these techniques helps to initiate appropriate and timely treatment, which is vital to prevent a fatal outcome.

Analysis of pathogenetic process of fungal rhinosinusitis: Report of two cases

BACKGROUND

Fungal rhinosinusitis is an infectious and/or allergic disease caused by fungi in the sinus and nasal cavity. Due to the warm and humid climate in Guangxi Zhuang Autonomous Region, the incidence of fungal rhinosinusitis is higher than that in other provinces. However, its physiological mechanism is not yet clear. Not every patient colonized by fungi develops a fungal infection. To a large extent, the immune status of the patient determines the nature of fungal disease in the nasal passages. The pathologic process of progression from harmless fungal colonization to fungal rhinosinusitis is unclear and has not been reported.

CASE SUMMURY

We report two patients, one who developed fungal rhinosinusitis 1.5 years after surgery performed to treat an inverted papilloma, and the other with a history of hypertension and cerebral infarction. Both patients recovered from their surgeries. An average time of 2.5 years elapsed from the development of maxillary sinus cysts to the development of fungal rhinosinusitis.

CONCLUSION

According to these case reports, we speculate that the progression of fungal rhinosinusitis from harmless colonization to disease onset requires approximately one to three years and that the length of the process may be related to underlying diseases, surgical treatment, deficient autoimmune status, and abuse of hormone antibiotics and hormones. Additional data are needed to conduct relevant studies to appropriately prevent and treat fungal rhinosinusitis.

An unusual presentation of sphenoid Candida fungal ball: a case report

The clinical presentation of a sphenoid fungal ball (FB) is often non-specific and tends to be overlooked, particularly in hosts with an intact immune status. Rarely, potentially life-threatening complications may arise, owning its anatomical characteristics with contiguous structures. Herein, we present an unusual case of sphenoid FB complicated with orbital apex syndrome in an immunocompetent patient. The diagnosis dilemma and subsequent management are further discussed.

Fungal Rhinosinusitis: Unravelling the Disease Spectrum

Fungal rhinosinusitis (FRS), once considered a rare disease, has seen a steep rise in incidence in recent times. This global rise in the burden of fungal disease is a consequence of an increment in the population with weakened immune systems. Increased life expectancy with rise in conditions like diabetes mellitus, medical advancements with invasive interventions, use of immunosuppressive drugs and chemo-radiotherapy all lead to unique risk situations. The situation becomes more alarming with the fact that there has been a significant rise in cases in immune-competent hosts with no predisposing factors. FRS represents a wide spectrum of disease ranging from the mild form of superficial colonization, allergic manifestations to life threatening extensive invasive disease. The categorization of disease into acute and chronic and invasive or noninvasive is important factor with implications in disease management and prognosis and this has been emphasized greatly in recent years. Diagnosis of FRS has been a challenge as the presenting clinical signs and symptoms and radiographic manifestations are often nonspecific. Definitive diagnosis requires direct fungi identification and hence culture and microscopic examination remain the gold standard. Availability of advanced and rapid diagnostic techniques is rare in majority of developing nations. Therapeutic dilemmas are another aspect of the management of FRS as in spite of the availability of new antifungal drugs, treatment is often empirical due to non-availability of early diagnosis, rapid disease progression and high costs of antifungal drugs. A description of the different types of FRS, their diagnosis and management has been presented in this review.

Basilar Occlusion and Rupture Secondary to Rare Fungal Sinusitis

BACKGROUND

Intracranial vascular infections of fungal etiology are extremely rare. Most cases occur in immunocompromised patients with invasive fungal disease, most commonly originating in the paranasal sinuses or the lungs. Granulomatous invasive rhinosinusitis, which is extremely rare in North America, has been reported to affect immunocompetent patients in most cases, and its causative strain has potential to invade the intracranial arteries. We present a rare case of basilar artery rupture and infarction secondary to granulomatous invasive rhinosinusitis.

CASE DESCRIPTION

A 50-year-old man in Florida presented with ischemic symptoms and a 6-month history of headache, dizziness, and falls. After biopsy, the patient developed subarachnoid hemorrhage and thrombosis. Several thrombectomy attempts were performed, resulting in persistent occlusion of the basilar artery and subsequent comatous state. After discussion with the patient's family, compassionate weaning and autopsy were authorized.

CONCLUSIONS

Invasive fungal rhinosinusitis is more frequent nowadays owing to increased use of immunosuppressive therapies. However, it is still a disease that mostly affects immunocompromised patients. The development of new microbiologic investigation techniques has enabled the discovery of fungal diseases that can also affect immunocompetent hosts, such as granulomatous invasive rhinosinusitis. This is an extremely rare condition in North America, with very few cases documented in the last few decades.

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

Objective

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

Study Design

Monocentric retrospective analysis.

Setting

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

Subjects and Methods

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

Results

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

Conclusion

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

Invasive fungal sinusitis: treatment of the orbit

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Managing acute invasive fungal sinusitis

Acute invasive fungal sinusitis is the most aggressive form of fungal sinusitis and can be fatal, especially in patients who are immunosuppressed. Early diagnosis and intervention are crucial and potentially lifesaving, so primary care providers must maintain a high index of suspicion for this disease. Patients may need to be admitted to the hospital for IV antifungal therapy and surgical debridement.

Sinonasal Fungal Infections and Complications: A Pictorial Review

Fungal infections of the nose and paranasal sinuses can be categorized into invasive and non-invasive forms. The clinical presentation and course of the disease is primarily determined by the immune status of the host and can range from harmless or subtle presentations to life threatening complications. Invasive fungal infections are categorized into acute, chronic or chronic granulomatous entities. Immunocompromised patients with poorly controlled diabetes mellitus, HIV and patients receiving chemotherapy or chronic oral corticosteroids are mostly affected. Mycetoma and Allergic Fungal Rhinosinusitis are considered non-invasive forms. Computer tomography is the gold-standard in sinonasal imaging and is complimented by Magnetic resonance imaging (MRI) as it is superior in the evaluation of intraorbital and intracranial extensions. The knowledge and identification of the characteristic imaging patterns in invasive - and non- invasive fungal rhinosinusitis is crucial and the radiologist plays an important role in refining the diagnosis to prevent a possible fatal outcome.

Magnetic resonance imaging in sinonasal disease

Computed tomography (CT) is often the primary imaging modality for the evaluation of sinonasal disease. For some indications, magnetic resonance imaging (MRI) may provide additional information. There are established indications for using MRI in complicated sinonasal inflammatory disease, invasive fungal sinus disease, and sinonasal mass lesions. When MRI is used in the evaluation of sinonasal disease, it is usually used as a complementary modality in addition to CT. Magnetic resonance imaging in sinonasal disease can be used to further characterize the primary sinonasal disease process and to evaluate the extent of complications such as orbital or intracranial involvement. When MRI is used in sinonasal disease, it should be evaluated in the context of the clinical situation and CT imaging features. This will help radiologists provide a meaningful differential diagnosis to assist in clinical management.