Prevention and prophylaxis of invasive fungal sinusitis in the immunocompromised patient

Clearing the Air: Acute Invasive Fungal Rhinosinusitis in Hematologic Cancer Patients

OBJECTIVES

Air quality has been shown to impact the rates of fungal infection of the airway, causing diseases such as acute invasive fungal rhinosinusitis (AIFRS), particularly in immunocompromised patients. We theorize that patients with hematologic malignancies in units with aging air handling units (AHUs) have a higher attack rate of AIFRS.

METHODS

Retrospective chart review identified patients with hematologic malignancy and AIFRS in two distinct and equal time periods between 2013 and 2022, representing the presence of aging AHUs and new AHUs, respectively. Cubic feet per minute (CFM) air flows, AIFRS attack rates, and clinical data were compared between the two groups and statistical analyses performed.

RESULTS

The older AHUs produce air flow of 27,610 CFM and the newer AHUs produce air flow of 80,000 CFM. There were 18 patients with air supplied by older AHUs and 7 patients with air supplied by new AHUs who developed AIFRS. There was a significantly higher AIFRS attack rate for patients supplied by the older AHUs compared with patients supplied by newer AHUs (p = 0.033). The patients supplied by the older AHUs tended to be younger. The white blood cell counts, absolute neutrophil counts, and the mean time to diagnosis did not differ between the two groups.

CONCLUSIONS

To our knowledge, this is the first study to examine AIFRS in immunocompromised patients' inpatient environment. Further research should explore whether higher CFM AHUs can decrease this disease among our most vulnerable patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Results of endoscopic nasal surgery in the treatment of invasive fungal sinusitis in children with cancer and immunosuppression

BACKGROUND AND OBJECTIVE

to describe the results of the treatment of invasive fungal sinusitis with nasal endoscopic surgery in an immunocompromised paediatric oncological population.

METHODS

retrospective study of all patients diagnosed with invasive fungal sinusitis operated in the National Paediatric Oncology Unit between 2012 and 2016. Data taken from their medical history included: epidemiological characteristics, oncological diagnosis, haematological data, symptoms, tomographic studies, surgical interventions, results of pathology and cultures, medications received, complications, evolution and survival.

RESULTS

18 patients were identified, 7 male and 11 female. The average age was 12 years, 13 had a diagnosis of acute lymphocytic leukemia and 5 of acute myeloid leukemia. Seventeen patients presented severe neutropenia at the time of diagnosis. The most frequently identified aetiological agent was Aspergillus in 13 patients. In 16 patients (89%) the disease was controlled with nasal endoscopic surgery. Ten patients died due to unrelated causes throughout the study.

DISCUSSION AND CONCLUSIONS

Invasive fungal sinusitis should be considered a medical emergency due to its high mortality. The diagnosis is based on a high index of suspicion in patients with predisposing factors (leukaemia, neutropenia, persistent fever, nasogastric tube) and endoscopic nasal evaluation. Antifungal medical treatment and aggressive nasal endoscopic surgery is indicated regardless of the patient's condition to reduce the fungal burden and associated high mortality. The treatment must be provided by a multidisciplinary team that includes paediatrics, haemato-oncology, infectology and otorhinolaryngology.

Sinonasal mucormycosis in immunocompromised pediatric patients

OBJECTIVE

Sinonasal mucormycosis is a rare fulminant disorder that typically affects immunocompromised patients. This article focuses primarily on the clinical manifestations and the importance of early diagnosis and treatment of this disease.

PATIENTS AND METHODS

Four pediatric cases of sinonasal mucormycosis encountered over an 8-year-period in our institution are reported. The initial presenting symptoms, physical examination, computed tomography, intraoperative, and histopathologic findings are described. The underlying immunosuppressive diseases are also outlined.

RESULTS

The most common signs and symptoms were fever, rhinorrhea, facial erythema and edema, and very pale nasal mucosa. Despite these manifestations, the diagnosis of sinonasal mucormycosis was delayed, except in one child. Computed tomography scan findings were nonspecific and did not correlate well with surgical and pathologic findings. Treatment consisted in a combination of antifungal agents, multiple aggressive surgical debridements, and control of the underlying disease. In the postoperative course, 1 child died of the disease, 1 developed a persistent unilateral blindness, 1 was lost to follow-up, and the last 1 was cured with no sequelae.

CONCLUSIONS

Sinonasal mucormycosis in the immunocompromised pediatric population is an uncommon but potentially fatal disease. A high index of suspicion is of utmost importance to decrease its related morbidity and mortality.

Epidemiology and Medical Mycology of Fungal Rhinosinusitis

Fungal rhinosinusitis (FRS) refers to a spectrum of disease ranging from benign colonization of the nose and sinuses by pathogenic fungi to acute invasive and fatal inflammation extending to the orbit and brain. FRS is classified into two categories: invasive and noninvasive. Invasive FRS may again be subcategorized into acute invasive (fulminant) FRS, granulomatous invasive FRS, and chronic invasive FRS; while noninvasive FRS is subcategorized into localized fungal colonization, sinus fungal ball and eosinophil related FRS (including allergic fungal rhinosinusitis, eosinophilic fungal rhinosinusitis). This classification is not without controversies, and intermediate and semi-invasive forms may also exist in particular patients. Acute invasive FRS is an increasingly common disease worldwide among the immunocompromised patients and caused most frequently by Rhizopus oryzae, and Aspergillus spp. Granulomatous invasive FRS has mostly been reported from Sudan, India, and Pakistan and is characterized by noncaseating granuloma formation, vascular proliferation, vasculitis, perivascular fibrosis, sparse hyphae in tissue, and isolation of A. flavus from sinus contents. Chronic invasive FRS is an emerging entity occurring commonly in diabetics and patients on corticosteroid therapy, and is characterized by dense accumulation of hyphae, occasional presence of vascular invasion, sparse inflammatory reaction, involvement of local structures, and isolation of A. fumigatus. While localized fungal colonization describes the most benign of all fungal sinusitis in the superficial nasal crusts, sinus fungal ball is a dense mycetoma like aggregate of fungal hyphae in diseased sinuses. Common in southern Europe, especially France, majority of them are sterile on culture while 30-50% may yield Aspergillus spp. The definitions and pathogenesis of the group of syndromes in eosinophil related FRS (AFRS, EFRS) are contentious and a matter of intense research among otolaryngologists, pathologists, immunologists and microbiologists. While dematiaceous fungi are the foremost initiators of these syndromes in the west, Aspergillus flavus is the predominant pathogen in India and the Middle-East.