A case of invasive rhinosinusitis by Fusarium verticillioides (Saccardo) Nirenberg in an apparently immunocompetent patient

Invasive fusariosis

Invasive fusariosis is a serious invasive fungal disease, affecting immunocompetent and, more frequently, immunocompromised patients. Localized disease is the typical clinical form in immunocompetent patients. Immunocompromised hosts at elevated risk of developing invasive fusariosis are patients with acute leukemia receiving chemotherapeutic regimens for remission induction, and those undergoing allogeneic hematopoietic cell transplant. In this setting, the infection is usually disseminated with positive blood cultures, multiple painful metastatic skin lesions, and lung involvement. Currently available antifungal agents have poor in vitro activity against Fusarium species, but a clear-cut correlation between in vitro activity and clinical effectiveness does not exist. The outcome of invasive fusariosis is largely dependent on the resolution of immunosuppression, especially neutrophil recovery in neutropenic patients.

Fusarium spp. in Human Disease: Exploring the Boundaries between Commensalism and Pathogenesis

Fusarium is a large fungal genus that is widely distributed in the environment, mostly known for its plant pathogenicity. Rarely, it is involved in human pathology, where the type of infection caused is highly dependent upon the portal of entry and the immune status of the host. The study at hand aims to summarize routine methods used in diagnosing such infections as well as more advanced molecular diagnostic methods, techniques that can play a huge role in differentiating between colonization and infection when trying to decide the therapeutic outcome. Consequently, to further support our findings, two different strains (one isolated from corneal scrapings and one isolated from purulent discharge) were analyzed in a clinical context and thoroughly tested using classical and modern diagnostic methods: identification by macroscopical and microscopical examinations of the culture and mass spectrometry, completed by molecular methods such as PCR for trichothecene and ERIC-PCR for genetic fingerprinting. Isolation of a clinically relevant Fusarium spp. from a sample still remains a diagnostic challenge for both the clinician and the microbiologist, because differentiating between colonization and infection is very strenuous, but can make a difference in the treatment that is administered to the patient.

Intracranial fusarium fungal abscess in an immunocompetent patient: case report and review of the literature

Introduction Fusarium spp is an omnipresent fungal species that may lead to fatal infections in immunocompromised populations. Spontaneous intracranial infection by Fusarium spp in immunocompetent individuals is exceedingly rare.

Case Report An immunocompetent 33-year-old Hispanic woman presented with persistent headaches and was found to have a contrast-enhancing mass in the left petrous apex and prepontine cistern. She underwent a subsequent craniotomy for biopsy and partial resection that revealed a Fusarium abscess. She had a left transient partial oculomotor palsy following the operation that resolved over the next few weeks. She was treated with long-term intravenous antifungal therapy and remained at her neurologic baseline 18 months following the intervention.

Discussion To our knowledge, this is the first reported case of Fusarium spp brain abscess in an immunocompetent patient. Treatment options include surgical intervention and various antifungal medications.

Conclusion This case demonstrates the rare potential of intracranial Fusarium infection in the immunocompetent host, as well as its successful treatment with surgical aspiration and antifungal therapy.

Invasive fungal sinusitis of the sphenoid sinus

Objective

This study was conducted to present the clinical outcome of invasive fungal sinusitis of the sphenoid sinus and to analyze clinical factors influencing patient survival.

Methods

A retrospective review of 12 cases of invasive fungal sphenoiditis was conducted.

Results

Cases were divided into acute fulminant invasive fungal spheonoidits (n=4) and chronic invasive fungal sphenoiditis (n=8). The most common underlying disease was diabetes mellitus (n=9). The most common presenting symptoms and signs included visual disturbance (100%). Intracranial extension was observed in 8 patients. Endoscopic debridement and intravenous antifungals were given to all patients. Fatal aneurysmal rupture of the internal carotid artery occurred suddenly in two patients. The mortality rate was 100% for patients with acute fulminant invasive fungal sphenoiditis and 25% for patients with chronic invasive fungal sphenoiditis. In survival analysis, intracranial extension was evaluated as a statistically significant factor (P=0.027).

Conclusion

The survival rate of chronic invasive fungal sphenoiditis was 75%. However, the prognosis of acute fulminant invasive fungal sphenoiditis was extremely poor despite the application of aggressive treatment, thus, a high index of suspicion should be required and new diagnostic markers need to be developed for early diagnosis of invasive fungal sinusitis of the sphenoid sinus.

Fusarium infection: report of 26 cases and review of 97 cases from the literature

Fusarium species is a ubiquitous fungus that causes opportunistic infections. We present 26 cases of invasive fusariosis categorized according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria of fungal infections. All cases (20 proven and 6 probable) were treated from January 2000 until January 2010. We also review 97 cases reported since 2000. The most important risk factors for invasive fusariosis in our patients were compromised immune system, specifically lung transplantation (n = 6) and hematologic malignancies (n = 5), and burns (n = 7 patients with skin fusariosis), while the most commonly infected site was the skin in 11 of 26 patients. The mortality rates among our patients with disseminated, skin, and pulmonary fusariosis were 50%, 40%, and 37.5%, respectively. Fusarium solani was the most frequent species, isolated from 49% of literature cases. Blood cultures were positive in 82% of both current study and literature patients with disseminated fusariosis, while the remaining 16% had 2 noncontiguous sites of infection but negative blood cultures. Surgical removal of focal lesions was effective in both current study and literature cases. Skin lesions in immunocompromised patients should raise the suspicion for skin or disseminated fusariosis. The combination of medical monotherapy with voriconazole or amphotericin B and surgery in such cases is highly suggested.

Maxillary rhinosinusitis due to Fusarium species leading to cavernous sinus thrombosis

Fungal rhinosinusitis is being recognized and reported with increasing frequency over the last two decades worldwide. Intracranial extension is the most dreaded complication of fungal sinusitis with high mortality rates. We report a case of chronic rhinosinusitis in a 55-year-old diabetic male, caused by Fusarium species. The patient was diagnosed as a case of chronic left maxillary sinusitis with cavernous sinus thrombosis. The sinus lavage showed fungal elements on direct microscopic examination and culture revealed growth of Fusarium species within 4 days of incubation. Conservative therapy with IV amphotericin B resulted in favorable outcome of the patient. This is an extremely rare case where cavernous sinus thrombosis occurred as a complication secondary to Fusarium species rhinosinusitis.

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.