Histopathology Of Sinonasal Fungal Disease

Sinonasal Bacteroma/Bacteria-related Concretions: A Distinct Pathologic Entity of the Sinonasal Tract

Patients can be seen where "fungal debris," "mycetoma," or "mass-like obstruction" of the sinonasal tract is suspected clinically but lack fungus and instead have granular, eosinophilic debris and bacterial colonies. We report and characterize 15 such cases, tentatively termed "bacteromas," compared with randomly selected cases of mycetoma and allergic fungal sinusitis (AFS). Pathology reports from 2016 to 2021 were searched. All candidate cases were examined microscopically and included if they had granular, amorphous debris with negative Grocott methenamine silver staining and lacked diagnostic features of other entities. The 7 males and 8 females ranged from 21 to 78 years old. Imaging frequently revealed opacification of the paranasal sinuses. Operative reports showed all to have paranasal sinus involvement. Most were unilateral (13/15, 87%). The maxillary sinus was involved in 11/15 (73%) cases, sphenoid sinus in 2/15 (13%), and frontal and ethmoid sinuses in 1/15 (7%), each. Bacteroma patients frequently had a history of allergic rhinitis (8/15, 53%), more than mycetomas (1/15, 7%) and AFS (5/15, 33%) ( P =0.0142). Facial pain was a common presenting symptom (13/15, 87%) in bacteromas compared with mycetomas (5/15, 33%) or AFS (1/15, 7%). Morphologically, cases consisted of large aggregates of paucicellular to acellular debris with a characteristic densely eosinophilic granular appearance, commonly associated with bacteria. Four of the 10 cultured patients grew Pseudomonas aeruginosa . Course posttreatment ranged from symptom resolution 1 week postoperatively to recurrent infections and symptoms 23 months from the initial operation. In summary, "bacteroma" is a heretofore undescribed pathologic entity of the sinuses that appears to be related to chronic bacterial infection and is distinct from mycetoma, AFS, and rhinolithiasis.

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.

Invasive Fungal Sinusitis with Ophthalmological Complications: Case Series and Review of the Literature

Invasive fungal sinusitis can lead to dramatic complications in immunocompromised patients and requires prompt diagnosis. Here we report three cases with ophthalmological complications secondary to invasive fungal sinusitis in immunocompromised patients. From an ophthalmological point of view, these cases illustrate different clinical presentations, evolutions, complications, treatments, prognoses, and highlight different pathophysiological mechanisms. Diagnoses were delayed in all cases. In none of the cases did patients recover better vision than counting fingers at 24 months follow up, and two patients died. This case series highlights key points useful for quickly recognising this highly morbid infection in immunocompromised patients.

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.

[Histopathological Diagnosis of Fungal Sinusitis and Variety of its Etiologic Fungus]

 Fungal sinusitis is divided into two categories depending on mucosal invasion by fungus, i.e., invasive and noninvasive. Invasive fungal sinusitis is further divided into acute and chronic disease based on time course. Noninvasive fungal sinusitis includes chronic noninvasive sinusitis (fungal ball type) and allergic fungal sinusitis. Chronic noninvasive sinusitis is the most predominant fungal sinusitis in Japan, followed by allergic fungal sinusitis. Invasive fungal sinusitis is rare. Hyphal tissue invasion is seen in invasive fungal sinusitis. Acute invasive fungal sinusitis demonstrates hyphal vascular invasion while chronic invasive fungal sinusitis usually does not. Fungal tissue invasion is never found in noninvasive sinusitis. A fungal ball may exist adjacent to sinus mucosa, but its hyphae never invade the mucosa. Fungal balls sometimes contain conidial heads and calcium oxalate, which aid in identifying the fungus in the tissue. Allergic fungal sinusitis is characterized by allergic mucin that is admixed with numerous eosinophils and sparsely scattered fungal elements. Histopathology is important in classifying fungal sinusitis, especially in confirming tissue invasion by the fungus.

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.

Experimental Model of Fungal Sinusitis: A Pilot Study in Rabbits

We have established an experimental model of fungal sinusitis in rabbits to analyze the chronology and the pathogenesis of the development of noninvasive fungal sinusitis due to Aspergillus fumigatus. Thirty-four Pasteurella-free New Zealand white rabbits divided into three groups were included in this study. In the first group (10 rabbits), A fumigatus was inoculated into the maxillary sinus. In the second group (10 rabbits), A fumigatus was inoculated into the maxillary sinus in the presence of a wound in the mucosa. In the third group (14 rabbits), A fumigatus was inoculated into the maxillary sinus in the presence of a blocked ostium. On days 15 and 30, endoscopic, histopathologic, bacterial, and mycological examinations of both maxillary cavities and mucous membrane were performed. The rabbits were painlessly sacrificed 30 days after inoculation; mucosal and bone biopsies of the maxillary sinus cavities were performed for histopathologic studies. We found that noninvasive fungal sinusitis had been induced in 2 rabbits of the second group and 8 rabbits of the third group. We conclude that introduction of fungi into a sinus with a blocked ostium induces fungal sinusitis. The present model of experimental fungal sinusitis seems to be reproducible and suitable for further studies of the development of fungal sinusitis.

Sphenoid sinus aspergilloma in trans-sphenoidal surgery for pituitary adenomas

BACKGROUND

Simultaneous appearance of sphenoid sinus aspergilloma and pituitary adenoma is a very rare finding.

METHODS

Retrospective analysis of patients with sellar and sphenoid sinus mass lesions who underwent trans-sphenoidal surgery was performed. Demographic data, medical history, predisposing factors, clinical picture, neurological status and radiological findings were reviewed. All patients underwent a trans-sphenoidal microsurgical treatment, and acquired specimens underwent both histopathological and microbiological analysis.

RESULTS

Sphenoid sinus aspergilloma was encountered in seven patients. Three patients had an isolated sphenoid sinus aspergilloma and four patients with pituitary macroadenoma had a sphenoid aspergilloma as an incidental finding.

CONCLUSIONS

Sphenoid sinus aspergilloma can be found during trans-sphenoidal surgery for pituitary adenomas. Sphenoid sinus extirpation followed by adenomectomy is the treatment of choice unless invasive aspergilloma is encountered requiring additional antifungal therapy.

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

OBJECTIVE

Acute invasive fungal rhinosinusitis (AIFRS) is a serious disease with a high mortality and morbidity rate, which almost always affects immunocompromised patients and/or patients with diabetes mellitus. Our purpose was to present the diagnostic and therapeutic management and outcome of these patients.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

Twenty-six patients, who were operated on because of AIFRS between September 1999 and June 2009, were retrospectively evaluated in this study. Endoscopic surgery was used in 19 patients, and open surgical debridement was performed in seven patients.

RESULTS

Overall survival rate of the patients in the open surgery group (4 of 7; 57.1%) was similar to that of the endoscopically treated group (9 of 19; 47.3%). Thirteen patients (50%) died of complications related to the underlying disease (9 of 13; 69.2%) and AIFRS (4 of 13; 30.7%). AIFRS-specific survival rate is 76.5 percent; 90 percent (9 of 10) and 57.1 percent (4 of 7) for endoscopic and open surgery groups, respectively. Four patients who died had pathological diagnosis of mucormycosis ( P = 0.52).

CONCLUSION

AIFRS can be successfully treated with a combination of endonasal surgical debridement and antifungal medications. Endonasal approach is suitable for patients diagnosed in the early stages of the disease and provides a less traumatic option in those patients who already have a poor health status. Open surgery should be preferred in the presence of intraorbital extension, palatinal, and/or intracerebral involvement. Reversing the underlying disease process and immunosuppression is as important as the surgical and antifungal treatment.

Oral voriconazole for invasive fungal skull base infection

Background:

Intravenous amphotericin or intravenous voriconazole, both followed by oral voriconazole, have previously been given to treat invasive aspergillosis of the skull base.

Case report:

Exclusively oral voriconazole was used in an immunocompetent patient with biopsy-proven, invasive aspergillosis. She had a large, erosive lesion extending from the central skull base to the right orbit and ethmoid sinus, and displacing the right internal carotid artery. After four months of oral treatment as an out-patient, a repeated computed tomography scan showed a fully treated infection with post-infectious changes only, and treatment was terminated. Two years later, there had been no recurrence.

Conclusion:

Substantial cost savings were made by using exclusively oral treatment, compared with the use of intravenous voriconazole or amphotericin, or a switch strategy.

Sphenoid sinus aspergillosis simulating pituitary tumor in immunocompetent patient

Aspergillosis of the sphenoid sinus is rare in immunocompetent patients. It may be mistaken for a sellar region tumor. A 65-year-old, human immunodeficiency virus-negative man presented with a 3-week history of cranial nerve III paresis and visual deterioration. The patient had a long-term history of tobacco snuff abuse. CT scans and MRI demonstrated a space-occupying lesion of the sellar and sphenoid sinus region. Presumptive diagnosis of pituitary macroadenoma was made and the patient was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, a yellow-brownish gluey material with crumbly debris extruded and was aspirated. The dura was intact. Histopathology revealed numerous Aspergillus hyphae without tissue invasion. Postoperatively, the cranial nerve III paresis resolved in a few days and visual acuity improved. Sphenoid sinus aspergillosis should be included in the differential diagnosis of sellar region processes, even in immunocompetent patients. Early diagnosis and transsphenoidal removal provides good results without the need for systemic antifungal therapy in non-invasive aspergillosis.

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

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

Nosocomial pulmonary Rhizopus diagnosed by bronchoalveolar lavage with cytology in a child with acute lymphoblastic leukemia

Rhizopus species is an opportunistic fungus that is contracted by inhalation of aerosolized spores. Early diagnosis is often difficult but is a necessity to prevent rapid progression of the infection that leads to blood vessel invasion by hyphae, causing fatal hemoptysis. A previous case report described the utility of cytologic examination of bronchoalveolar lavage (BAL) fluid in achieving a prompt diagnosis of Rhizopus species in an adolescent patient with diabetic ketoacidosis. The author presents a case that further describes the benefit of performing BAL fluid cytology to help identify fungal morphology characteristics in order to reach an expeditious diagnosis of Rhizopus species in a leukemia patient.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

Fungal sinusitis: histologic spectrum and correlation with culture

Fungi are important etiologic agents of sinusitis. However, features of fungal sinusitis including the histologic spectrum, diagnostic mishaps, incidence, and fungal types have not been systematically studied. From 1996 through 2001, a total of 788 surgical pathology sinus specimens from 384 cases was retrieved. Fungal sinusitis was diagnosed in 58 specimens (7%) from 47 cases (12%). Four histologic categories of fungal sinusitis were identified: (1) allergic fungal sinusitis in 34 cases (copious mucin, abundant eosinophils, Charcot-Leyden crystals (so-called allergic mucin), with rare noninvasive fungal hyphae); (2) mycetoma/fungus ball in 11 cases (tightly packed fungal hyphae without allergic mucin or tissue invasion); (3) chronic invasive fungal sinusitis in 1 case (tissue granulomas with fungal hyphae); and (4) acute fulminant fungal sinusitis in 1 case (fungal vascular invasion). The diagnosis was initially missed in 16/34 (47%) cases of allergic fungal sinusitis despite typical features; incorrect classification was noted in 47% of cases. Sixty-seven percent of cases had positive fungal cultures, dematiaceous fungi being the most common. Allergic fungal sinusitis accounted for the majority of fungal sinusitis. Although misdiagnosis or incorrect classification is rather frequent for fungal sinusitis, awareness of the distinctive morphologic features of this entity may prevent these errors.

Sinonasal aspergillosis in immunocompetent Indian children: an eight-year experience

A retrospective study of 40 otherwise healthy children suffering from paranasal aspergillosis is presented. Fifteen percentage of this group was under 10 years of age. The clinical characteristics were marked facial deformity, orbital involvement (52.5%) and skull base erosion (12.5%). Ethmoid sinus was the commonest sinus to be affected. Aspergillus serology was positive in 35% and fungal culture grew the organism in 40%. Histopathology revealed allergic or non-invasive fungal infections without any tissue invasions. Surgery was performed in all except one case. Recurrence was 15% treated by revision surgery and antifungal therapy.

Fungal sinusitis in the immunocompetent patient: risk factors and surgical management

BACKGROUND

Fungal sinusitis has been reported increasingly in immunocompetent patients. However, the most effective, appropriate mode of therapy has not been determined.

MATERIALS AND METHODS

In this retrospective study, we examined the records of 110 immunocompetent patients with chronic sinusitis who had undergone sinus surgery at our institution between 1983 and 1994. Five patients (4.5%) with fungal sinusitis were identified. Information on those patients was compared with that of the 105 patients with nonfungal sinusitis.

RESULTS

Prolonged use of topical steroids was no more common in patients with fungal sinusitis (20%) than it was in patients with nonfungal sinusitis (4.8%) (p = 0.25). Differentiating features of fungal sinusitis were the presence of a metallic density and areas of high- and low-density on radiologic examination (p < 0.01). All five of the patients with fungal sinusitis were cured by surgical intervention, primarily endoscopic sinus surgery, without undergoing anti-mycotic therapy. Four of the five patients were followed up for at least 3 years without any recurrence.

CONCLUSION

Endoscopic sinus surgery is and should remain the mainstay of treatment for fungal sinusitis in immunocompetent patients. Adjunctive anti-mycotic therapy may not be necessary.

[Sino-nasal endoscopic surgery in fungal sinusitis. Our experience]

Fungal sinusitis is a rare entity which has increased amongst immunocompromised individuals. Records of thirteen patients treated of fungal sinus disease between 1995 and 2001 were reviewed. Histopathological studies demonstrated infection due to Aspergillus in eight patients and due to Mucormycosis in five patients. The surgical debridement via endoscopic sinus surgery was the essential part of the management. The follow-up is 12-72 months (mean 29.08). The main clinical findings and a review of the literature are presented. We conclude that endoscopic sinus surgery is the treatment of choice for fungal sinusitis except in advanced cases of mucormycosis in which a combined approach is still necessary together with intravenous antifungal drugs (amphotericin B).

Invasive sino-nasal pseudallescheriasis in a non-immunocompromised patient

Pseudallescheriasis is a spectrum of clinical diseases involving Pseudallescheria boydii, a soil and water inhabiting fungus. The organism is of low virulence, but is a fungal opportunist able to elicit infections similar in terms of variety and pre disposing factors to those of Aspergillus species(3). Involvement of the nose and the sinuses is very rare(7). Here we present a case of invasive Pseudallescheriasis involving the nose, paranasal sinuses and orbit in a non-immunocompromised person. Surgical debridement followed by systemic antifungal therapy was given. The fungus resembles hyaline moulds like Aspergillus very closely in tissue sections and can be a diagnostic challenge to the pathologist.

Chronic invasive fungal rhinosinusitis

Chronic invasive fungal rhinosinusitis is an increasingly recognized, but inadequately characterized, disease entity which is separate and distinct from acute fulminant invasive fungal sinusitis and allergic fungal sinusitis. Chronic invasive fungal rhinosinusitis is divided into granulomatous and nongranulomatous subtypes based on histopathology, but the clinical distinction between the two subtypes is not clear. Current management includes varying degrees of surgical débridement and a prolonged course of antifungal agents. A protracted clinical course with recurrence after treatment is common.

Fungal sinusitis

Until several years ago, no criteria for diagnosis or consensus on the classification of fungal sinusitis existed. Many reports were grouped under the heading of "aspergillus sinusitis," regardless of invasiveness; thus, published information on the diagnosis, natural history, and treatment of fungal sinusitis was of limited value. Diagnostic criteria and clinical descriptions for allergic fungal sinusitis, sinus mycetoma, and invasive fungal sinusitis have now been published. These criteria, a new classification system, and the clinical approach to patients with fungal sinusitis are reviewed in this article. Although fungal sinusitis is not a rare disease, much remains to be learned about its optimal clinical management.

Rabbit as an animal model of paranasal sinus mycoses

Paranasal sinus mycoses are endemic in rural populations of northern India. To study host-parasite interactions, we developed an animal model of paranasal sinus mycoses. After failure in small animals such as mice and rats, we used New Zealand white rabbits weighing 2.5-3 kg. Inoculum sizes consisted of 0.75-1.0 x 10(8), 0.75-1.0 x 10(7), 0.75-1.0 x 10(6) conidia of a clinical isolate of Aspergillus flavus. The inoculum was injected at a spot 0.5 cm in front of the alveolar process of the maxilla and 0.5 cm below the maxillary process of frontal bone and vertically to a depth of 0.5 cm across the bone directly into the nasal sinus. Paranasal sinus mycoses proven by culture and histopathology developed in 67% of animals injected with 0.75-1.0 x 10(8) conidia and 17% of animals with 0.75 x 10(7) conidia. No lesions were found in the group injected with 0.75-1.0 x 10(6) conidia. Precipitating antibody against culture filtrate antigen was found in rabbits with paranasal sinus mycoses. Therefore, rabbits can be used as an animal model to study paranasal sinus mycoses.

In situ hybridization for Aspergillus and Penicillium in allergic fungal sinusitis: a rapid means of speciating fungal pathogens in tissues

Allergic fungal sinusitis (AFS) is a serious form of sinonasal fungal disease that is commonly associated with Aspergillus or Dematiaceous fungi. This study was performed to determine the incidence of Aspergillus or Penicillium in AFS by using in situ hybridization (ISH) for Aspergillus and Penicillium ribosomal RNA (rRNA). The Fontana-Masson melanin stain (FMMS) was also used to detect pigmented fungi (A. niger and Dematiaceous fungi). ISH was performed on 26 patients: 17 AFS cases with histologic evidence of fungi, 5 AFS cases without histologic evidence of fungi, 3 cases of invasive fungal sinusitis (IFS), and 1 case of fungus ball. Nine AFS specimens with histologic evidence of fungi were ISH positive. Positivity was also noted in two of three IFS cases, while no staining was seen in the fungus ball and in six AFS specimens without fungi demonstrable by silver stains. Six ISH-positive cases were FMMS positive, suggesting A. niger. Five ISH-negative AFS specimens were FMMS positive, suggesting Dematiaceous fungi. In summary, many AFS patients in our institution demonstrate Aspergillus/Penicillium organisms. Ancillary techniques may help identify fungi responsible for AFS if cultures are negative or not performed. ISH for rRNA is a useful means for rapidly speciating fungi in human tissues.

Functional endoscopic sinus surgery and 109 mycetomas of paranasal sinuses

Mycetomas of paranasal sinuses are more frequently diagnosed with the widespread use of nasal endoscopy and computed tomography (CT). We present a series of 109 cases treated by functional endoscopic sinus surgery (FESS) with a mean follow-up of 29 months. All localizations were seen, and contrary to what was initially thought, seven cases presented in multiple sites. Several clinical presentations were found, from a pansinusal involvement to a simple mycetoma hanging in a superior meatus. A heterogeneous sinus opacity with microcalcifications on CT scan is very suggestive of the diagnosis, but a homogeneous opacity may be encountered even with bone lysis. FESS was performed in all cases to obtain a wide opening of the affected sinuses, permitting a careful extraction of all fungal material. In the postoperative period, no medical treatment is prescribed. With a mean follow-up of 29 months, only four recurrences were seen. This study reinforces the interest in FESS for cases of mycetoma of the paranasal sinuses.

The spectrum of orbital aspergillosis: a clinicopathological review

Orbital aspergillosis is an uncommon but serious infection that may first present to the ophthalmologist. Usually arising from the paranasal sinuses, it may present in manifold ways within the orbit. Some presentations, such as optic nerve involvement, can respond to systemic corticosteroids, leading to delays in diagnosis and possibly iatrogenic potentiation of the infectious process. In this review, pertinent clinical and radiographic findings are discussed, and the literature is summarized. Classic approaches to therapy include local treatment, debridement, and systemic amphotericin B. We review novel approaches to treating orbital aspergillosis and detail a flow-chart for its management. Four patients from the spectrum of orbital aspergillosis are also described: initially presenting as an infection of an exenteration socket, a complex dacryocystitis, and optic nerve tumor, and post-operative periorbital swelling. Physicians should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of invasive aspergillosis. In the neutropenic or otherwise immunocompromised patient, a high index of suspicion must be maintained as delays in diagnosis of fulminant aspergillosis may lead to overwhelming and rapidly progressive infection. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly itraconazole and liposomal amphotericin B, may be beneficial in selected patients.

Fungal sinusitis: an update

OBJECTIVE

To review the classification of fungal sinusitis as well as discuss current approaches to diagnosis and management.

DATA SOURCES

A MEDLINE literature search was performed using the index terms sinus infection, fungal, diagnosis, radiology, microbiology, and treatment. The search was restricted to the English language and human subjects. With one exception the references were restricted to the last 10 years. Clinical data from studies performed at our institution were also included.

RESULTS

Fungal sinusitis can be divided into four primary categories: (1) acute/fulminant (invasive), (2) chronic/indolent (invasive), (3) fungus ball, and (4) allergic fungal sinusitis. Each subtype has unique immunologic, pathologic, and clinical features. Allergic fungal sinusitis is the most recently described and most common form. The treatment and prognosis of fungal sinusitis varies significantly among the four different categories.

CONCLUSION

Recent advances in endoscopy and computed tomography have enhanced the understanding of fungal sinusitis; however, they remain diseases surrounded by controversy. New insights into the etiology and pathogenesis of these diseases along with advances in diagnosis and treatment will lead to improved medical therapy.

Aspergillus sphenoid sinusitis-induced orbital apex syndrome in HIV infection

BACKGROUND

Orbital apex syndrome due to aspergillus sphenoid sinusitis is a rare condition. Human immunodeficiency virus (HIV) infection has recently been reported in aspergillus orbital abscess. To the authors' knowledge this is the first reported association of HIV with the orbital apex syndrome.

METHODS

A 37-year-old HIV-infected man presented with headache, reduced vision and progressive ophthalmoplegia in the right eye. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed sphenoid sinusitis. Sphenoid sinus biopsy was performed.

RESULTS

Light microscopy revealed infiltrative branching septate fungal hyphae. Fungal culture isolated Aspergillus fumigatus.

CONCLUSION

Atypical fungal infection such as Aspergillus fumigatus sphenoid sinusitis should be suspected in HIV-infected patients with orbital apex syndrome.