Syndromes of invasive fungal sinusitis

Metastatic Prostate Adenocarcinoma Masquerading as Invasive Fungal Sinusitis

A 58 year old male with a history of prostate adenocarcinoma presented with diplopia, severe headaches, and eye pain, consistent with sinusitis. Imaging was concerning for invasive fungal sinusitis (IFS) and an urgent ENT consultation was requested. Endoscopic sinus surgery was performed revealing metastatic prostate adenocarcinoma to the sinuses and anterior cranial fossa. The distinctive imaging features in this case are very useful when considering the divergent management options of IFS and metastatic sinus disease. These entities are likely to be encountered more frequently as immunomodulating therapies expand and prostate cancer continues to be a leading cause of death in males.

Is low dose of liposomal amphotericin B effective in management of acute invasive fungal rhinosinusitis? Our conclusions from Al-Mowassat University Hospital, Syria: a prospective observational study

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFRS) is a fatal infection associated with high morbidity and mortality. Although it is a rare disease, upsurge of AIFRS was noticed during the second wave of COVID-19 disease. Early diagnosis and management is the cornerstone for good outcomes. However, management of AIFRS is challengeable especially in developing countries due to limited resources and high prices of antifungal agents. No previous studies have been conducted to evaluate the outcomes of management of AIFRS in Syria. The purpose of this study is to report the results of management of AIFRS with low doses of liposomal amphotericin B in our tertiary hospital in Syria.

METHODS

The outcomes of management of AIFRS cases were followed through a prospective observational study between January 2021 and July 2022. The required medical data were collected for each individual. Three-month mortality rate was studied. SPSS v.26 was used to perform the statistical analysis. Pearson Chi-square test was used to study the associations between different variables and mortality. Survival curves were plotted by the Kaplan-Meier to compare the survival probability. Log Rank (Mantel-Cox) test and Cox regression were conducted to evaluate the factors affecting survival within the follow up period.

RESULTS

Of 70 cases, 36 (51.4%) were males and 34 (48.6%) were females. The mean age of patients was 52.5 years old. The most common underlying risk factor was diabetes mellitus (84.3%). The used dose of liposomal amphotericin B ranged between 2-3 mg/kg per day. The overall 3-month mortality rate was 35.7%. Significant association was found between survival and the following variables: Age, orbital involvement, stage, and comorbidity.

CONCLUSION

The overall mortality rate was close to other studies. However, survival rate was worse than comparable studies in selected cases of AIFRS (older ages, involved orbits, advanced stages, and chronic immunodeficiency). Therefore, low doses of liposomal amphotericin B could be less effective in such cases and high doses are recommended.

Microbial and clinical epidemiology of invasive fungal rhinosinusitis in hospitalized COVID-19 patients, the divergent causative agents

Since COVID-19 spread worldwide, invasive fungal rhinosinusitis (IFRS) has emerged in immunocompromised patients as a new clinical challenge. In this study, clinical specimens of 89 COVID-19 patients who presented clinical and radiological evidence suggestive of IFRS were examined by direct microscopy, histopathology, and culture, and the isolated colonies were identified through DNA sequence analysis. Fungal elements were microscopically observed in 84.27% of the patients. Males (53.9%) and patients over 40 (95.5%) were more commonly affected than others. Headache (94.4%) and retro-orbital pain (87.6%) were the most common symptoms, followed by ptosis/proptosis/eyelid swelling (52.8%), and 74 patients underwent surgery and debridement. The most common predisposing factors were steroid therapy (n = 83, 93.3%), diabetes mellitus (n = 63, 70.8%), and hypertension (n = 42, 47.2%). The culture was positive for 60.67% of the confirmed cases, and Mucorales were the most prevalent (48.14%) causative fungal agents. Different species of Aspergillus (29.63%) and Fusarium (3.7%) and a mix of two filamentous fungi (16.67%) were other causative agents. For 21 patients, no growth was seen in culture despite a positive result on microscopic examinations. In PCR-sequencing of 53 isolates, divergent fungal taxons, including 8 genera and 17 species, were identified as followed: Rhizopus oryzae (n = 22), Aspergillus flavus (n = 10), A. fumigatus (n = 4), A. niger (n = 3), R. microsporus (n = 2), Mucor circinelloides, Lichtheimia ramosa, Apophysomyces variabilis, A. tubingensis, A. alliaceus, A. nidulans, A. calidoustus, Fusarium fujikuroi/proliferatum, F. oxysporum, F. solani, Lomentospora prolificans, and Candida albicans (each n = 1). In conclusion, a diverse set of species involved in COVID-19-associated IFRS was observed in this study. Our data encourage specialist physicians to consider the possibility of involving various species in IFRS in immunocompromised and COVID-19 patients. In light of utilizing molecular identification approaches, the current knowledge of microbial epidemiology of invasive fungal infections, especially IFRS, may change dramatically.

Diagnostic and therapeutic strategies of acute invasive fungal rhinosinusitis

Acute invasive fungal rhinosinusitis (AIFR) is a rare disease, but the prognosis is by no means ideal. Pathologically, fungal infection is not only located in the sinus cavity, but also invades the sinus mucosa and bone wall, the surrounding structures and tissues such as the orbit and anterior skull base are often compromised and are accompanied with intracranial and extracranial complications. Despite decades of efforts, acute invasive fungal rhinosinusitis remains a devastating disease, the mortality of the disease continues to hover around 50%. The main impediments to improving the prognosis of acute invasive fungal rhinosinusitis are the difficulties of early diagnosis and the rapid reversal of immune insufficiency. Moreover, aggressive surgery combined with systemic antifungal therapy are significant positive prognostic factors as well. Progress and standardization of AIFR treatment protocols have been limited by the scarcity of the disease and the absence of published randomized studies. Therewith, how to improve the therapeutic outcome and reduce the mortality rate has always been a challenging clinical discussion. We have summarized the relevant case series and literature from the recent years, management with optimal diagnostic and curative strategies are reviewed.

Invasive aspergillosis in the patient with focal segmental glomerulosclerosis initiating hemodialysis: a case report and mini-review

Background

Invasive aspergillosis (IA) is a severe form of fungal infection caused by the genus Aspergillus in immunocompromised hosts and has a high mortality rate. End-stage kidney disease (ESKD) is one of the risk factors for developing fungal infection; however, the detailed clinical and treatment course of ESKD patients with IA has been scarcely reported, especially for the patient initiating hemodialysis (HD). Here, we experienced a patient under immunosuppressive therapy for focal segmental glomerulosclerosis (FSGS) who suffered from IA involving lung and brain and resulted in initiating HD.

Case presentation

A 66-year-old male patient with a history of suspected non-tuberculosis mycobacterial lung disease was initially admitted to the hospital with minimal change disease and subsequently diagnosed as FSGS with worsening urinary protein levels. The combined treatment including immunosuppressive treatments of cyclosporin and glucocorticoids and low-density lipoprotein apheresis was initiated, and then, he experienced the symptoms of dry cough, somnolence, and disorientation, which were subsequently diagnosed as IA involving lung and brain. The patient required renal replacement therapy, and maintenance HD was continued. Despite the intensive treatment with multiple antifungals of liposomal amphotericin B, voriconazole, micafungin, and amphotericin B, the pneumonia of the patient did not improve, and he subsequently passed away.

Conclusions

We report the case of the IA under immunosuppressive treatment, who was subsequently initiated maintenance HD. The detailed clinical course of medications used to treat the patient is presented with the literature review of IA in ESKD and HD patients and those with past acid-fast bacterial infections. The careful determination of the intensity of immunosuppression and monitoring of the patient’s symptoms and early definitive diagnosis is crucial in treating IA in immunocompromised hosts with ESKD or in HD under immunosuppressive treatment, as the mortality for these patients is suspected to be high despite the intensive treatment.

COVID-Associated Sinonasal Mucormycosis: Radiological Pathological Correlation and Prognostic Value of MR Imaging

Purpose  Our aim was to assess the sinonasal magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) in coronavirus disease (COVID)-associated mucormycosis (CAM) and to correlate these with histopathology and patient outcome in terms of duration of hospital stay and survival at 10 weeks. Methods  Twenty patients with histopathologically confirmed sinonasal CAM underwent MRI (including postcontrast T1-weighted and diffusion-weighted imaging). Histopathological findings (presence of coagulative necrosis, granulomatous reaction, and fungal burden) were recorded and all patients were followed up at 6 and 10 weeks. Statistical analysis was done using chi-square test and Fischer's exact test. Results  Enhancement patterns seen in our subjects included homogeneous, heterogeneous, and lack of contrast enhancement (LOC), with LOC being the most common (65%). Diffusion restriction was found in 90% patients. Statistically significant correlation was found between LOC pattern and presence of coagulative necrosis ( p -value = 0.007), extent of fungal hyphae ( p -value = 0.047), and duration of hospital stay ( p -value = 0.004). Restricted diffusion was also seen to correlate with a high fungal load ( p -value = 0.007). Conclusion  Our study describes the MRI findings of AIFRS in CAM and highlights the imaging features which may be surrogate markers for coagulative necrosis and fungal burden.

Mucormycosis, one month after recovery from COVID-19: A case report

Introduction

and importance: There are increasing case reports of mucormycosis in patient with coronavirus disease 2019 (Covid-19). Herein, we describe the case of mucormycosis after recovery from Covid-19.

Case presentation

The patient was a 73 years old woman with a history of chronic kidney disease, diabetes mellitus, hypertension, and dyslipidemia that referred to the emergency department with clinical presentation of Covid-19. On the third day of admission, the Covid-19 PCR test was negative, but the patient presented headache and pain in her upper jaw. Physical examination showed fever, erythema, and tenderness in the right cheek. Emergency biopsy and culture from sinus by subsection to mucormycosis conducted. and the diagnosis of mucormycosis was confirmed by the positive result of biopsy and culture. Despite anti-fungal treatment with Amphotericin B, patient developed severe diarrhea and became hemodynamically unstable. In the stool analysis, Strongyloides stercoralis was reported. Unfortunately, patient was expired on day thirty-two of this admission.

Clinical discussion

Mucormycosis is a dangerous infection, and its rapid diagnosis is so important. On the other hand, Covid-19 may associated with many nonspecific sign and symptoms. These finding may overlap with other infections.

In patients with prolonged mucormycosis infection, the development of strongyloidiasis should not be neglected. A single dose of ivermectin as strongyloidiasis prophylaxis should be given if the duration of the illness is prolonged.

Conclusion

Clinicians should consider mucormycosis and its complications after Covid-19 treatment in diabetic and immunocompromised patients.

•

COVID-19 may be associated with bacterial or fungal co-infections.

•

Nonspecific sign and symptoms of COVID-19, may overlap with other infections.

•

Mucormycosis may occur following COVID-19, especially in patients with risk factors.

•

We report a case of mucormycosis, one month after recovery from COVID-19 in a patient with poor diabetic control.

Invasive Rhinosinusitis Caused by Alternaria infectoria in a Patient with Autosomal Recessive CARD9 Deficiency and a Review of the Literature

Phaeohyphomycoses comprise a heterogeneous group of fungal infections caused by dematiaceous fungi and have primarily been reported in patients with underlying acquired immunodeficiencies, such as hematological malignancies or solid-organ transplants. Over the past decade, a growing number of patients with phaeohyphomycosis but otherwise healthy were reported with autosomal recessive (AR) CARD9 deficiency. We report a 28-year-old woman who presented with invasive rhinosinusitis caused by Alternaria infectoria. Following a candidate gene sequencing approach, we identified a biallelic loss-of-function mutation of CARD9, thereby further broadening the spectrum of invasive fungal diseases found in patients with inherited CARD9 deficiency. In addition, we reviewed 17 other cases of phaeohyphomycosis associated with AR CARD9 deficiency. Physicians should maintain a high degree of suspicion for inborn errors of immunity, namely CARD9 deficiency, when caring for previously healthy patients with phaeohyphomycosis, regardless of age at first presentation.

An integrative review on the uses of plant-derived bioactives formulated in conventional and innovative dosage forms for the local treatment of damaged nasal cavity

Plants and their derivates have been used as medicines for centuries and today is being re-discovered their usefulness for the human health. The therapeutic properties of phytochemicals are re-evaluated under the light of medical and pharmacological research, pushed by a constantly growing market demand, where consumers trust more natural products than synthetic drugs. New studies are enlightening the effectiveness of phytochemicals against a wide range of ailments, nevertheless very few evaluate the efficacy of topical formulations based on natural bioactive molecules in the treatment of nasal mucosal diseases. This review aims at exploring this little covered topic. An overview on the properties and functionality of the nasal mucosa and the different diseases affecting it has been provided. We summarized various nasal dosage forms containing natural bioactive and explored how innovative delivery systems loading phytochemicals can improve the treatment results. Finally, the potential use of novel nanocarriers for the treatment of nasal ailments has been covered as well.

Aspergillus fumigatus cerebral abscess and sphenoid sinus osteomyelitis in an immunocompetent patient following previous nasopharyngeal carcinoma and radiotherapy

Cerebral mycosis is extremely rare in immunocompetent patients. A 61-year-old male presented with a 3-month history of worsening left-sided headaches and 3-week history of left-sided upper lip paraesthesia. Magnetic resonance imaging revealed an enhancing lesion in the left temporal lobe. Histopathology of this lesion revealed what initially resembled a zygomycete but additional cultures obtained on further surgical debridement revealed the infection to be Aspergillus fumigatus with associated sphenoid sinus osteomyelitis. We postulate that the presentation was related to the patient’s previous radiotherapy for nasopharyngeal carcinoma. To the best of our knowledge, this is the only report of such a case.

Chronic Invasive Fungal Sinusitis With Negative Histopathology: A Diagnostic Challenge

Although the diagnosis of chronic invasive fungal sinusitis relies chiefly on identification of invasive fungi on histology, the insidious nature of the disease can preclude detection of fungal organisms. Here, we present a case of chronic invasive fungal sinusitis with negative histopathologic findings and a definitive diagnosis made through fungal DNA detection. Clinicians should consider polymerase chain reaction an important complement to histology and culture in the diagnosis of chronic invasive fungal sinusitis.

Paranasal sinusitis at the initiation of chemotherapy is a risk factor for invasive fungal disease in children and adolescents with cancer

BACKGROUND

The impact of paranasal sinusitis on the clinical outcome of patients with cancer remains unknown. The aim of this study was to determine whether paranasal sinusitis at the initiation of chemotherapy (SAI) affects the development of infectious complications in children and adolescents with cancer.

METHODS

A retrospective cohort analysis of patients aged 0-20 years with cancer who received chemotherapy was performed. SAI was defined as the presence of a fluid level or mucosal swelling or total opacity on sinus computed tomography examination before the initiation of chemotherapy. The primary outcome measures were the incidence of bacteremia, septic shock, and invasive fungal disease (IFD, including proven, probable, and possible cases).

RESULTS

SAI was observed in 57 (44%) of 130 enrolled patients. There were no significant differences in age, sex, and disease distribution between the patients with SAI (SAI group) and those without (non-SAI group). There was no significant difference in the 1-year cumulative incidence of bacteremia or septic shock after treatment initiation between the two groups (bacteremia, SAI group 33% vs. non-SAI group 35%, P = 0.53; septic shock, SAI group 4% vs. non-SAI group 4%, P = 0.87). The 1-year cumulative incidence of IFD was higher in the SAI group than in the non-SAI group (22% vs. 6%, P = 0.012). Cumulative incidence analysis after inverse probability of treatment weighting adjustment showed that the SAI group was more likely to develop IFD (HR: 3.5, 95% CI: 1.1-11.2, P = 0.033).

CONCLUSIONS

Our findings suggest that patients with SAI may be at higher risk for IFD during chemotherapy.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Chronic Invasive Fungal Rhinosinusitis in Immunocompetent Patients: A Retrospective Chart Review

Objective: We report cases of Chronic Invasive Fungal Sinusitis (CIFS) in patients considered as immunocompetent at tertiary care center (King Faisal Specialist Hospital), to analyze their clinical, biological, radiological features, and management. Material and methods: A retrospective chart review of CIFS in immunocompetent patients. The inclusion criteria as the following: immunocompetent patients of any age with histopathological findings of CIFS. Immunocompromised patients, acute Invasive Fungal Sinusitis (IFS), non-invasive fungal rhinosinusitis, and no positive histological findings were excluded. Results: Seventeen (17) patients were included. The species isolated included: Aspergillus (most frequent) & Mucor. Surgical treatment approaches were described. Complications reported include CSF leak, blindness, recurrence, and death. Conclusions: Early diagnosis and management of CIFS improve clinical outcomes.

A multi-institutional review of outcomes in biopsy-proven chronic invasive fungal sinusitis

BACKGROUND

Chronic invasive fungal sinusitis (CIFS) is a rare, life-threatening infection of the nose and sinuses. This study aims to identify factors that impact survival in 1 of the largest cohorts to date.

METHODS

Pathology records were reviewed for biopsy-proven CIFS from 3 tertiary academic institutions from 1995 to 2016. Variables were analyzed using log-rank survival analysis. Univariate Cox regression was performed at 1 and 12 months.

RESULTS

Thirty-eight patients were included. Hematologic malignancy and diabetes were the most common underlying diseases (32% each). Aspergillus was the most common fungus (63%). Greater than 75% of the patients had an absolute neutrophil count (ANC) >1000 at the time of diagnosis. Overall survival at 1, 6, and 12 months was 89%, 68%, and 48%, respectively. In univariate analysis, factors associated with worse survival included: ANC <500 at 12 months (hazard ratio [HR] 4.8; p = 0.01), ANC <1000 at 12 months (HR 5.8; p = 0.001), and recent chemotherapy (HR 4; p = 0.01). The following factor was associated with improved survival in univariate analysis: ANC as a linear variable in the entire cohort (HR 0.7; p = 0.005).

CONCLUSION

We present a multi-institutional case-series of CIFS and long-term follow-up. ANC <1000 at time of diagnosis and recent chemotherapy (within 1 month of diagnosis) are associated with poorer survival, whereas a rising ANC >1000 is associated with improved survival at 12 months. Further prospective studies are needed to further define factors that affect outcomes.

Allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a subset of chronic rhinosinusitis with nasal polyps (CRSwNP) characterized by antifungal IgE sensitivity, eosinophil-rich mucus (ie, allergic mucin), and characteristic computed tomographic and magnetic resonance imaging findings in paranasal sinuses. AFRS develops in immunocompetent patients, with occurrence influenced by climate, geography, and several identified host factors. Molecular pathways and immune responses driving AFRS are still being delineated, but prominent adaptive and more recently recognized innate type 2 immune responses are important, many similar to those established in patients with other forms of CRSwNP. It is unclear whether AFRS represents merely a more extreme expression of pathways important in patients with CRSwNP or whether there are other disordered immune responses that would define a distinct endotype or endotypes. Although AFRS and allergic bronchopulmonary aspergillosis share some analogous immune mechanisms, the 2 conditions do not occur commonly in the same patient. Treatment of AFRS almost always requires surgical debridement of the involved sinuses. Oral corticosteroids decrease recurrence after surgery, but other adjunctive pharmacologic agents, including topical and oral antifungal agents, do not have a firm evidence basis for use. There is good rationale for use of biologic agents that target eosinophilic inflammation or other type 2 responses, but studies in patients with AFRS are required.

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.

Impact of early detection of acute invasive fungal rhinosinusitis in immunocompromised patients

Background

Early diagnosis of acute invasive fungal rhinosinusitis (AIFRS) is vital to improving outcomes in immunocompromised patients. This study evaluated the impact of a systematic protocol with nasal endoscopy and biopsies to early detect AIFRS in immunocompromised patients. Additionally, we compared the accuracy of frozen-section biopsy and culture with formalin-fixed paraffin-embedded (FFPE) biopsy.

Methods

Retrospective cohort in a Tertiary Referral Hospital. Patients with the suspected diagnosis of AIFRS were evaluated following a standardized protocol, including serial nasal endoscopies and biopsies when necessary. The sensitivity and specificity of frozen-section biopsy and culture were also compared with FFPE.

Results

The mortality rate related to AIFRS of this standardized cohort (13/43) was 30.2%. Better outcomes were observed in patients with disease limited to the turbinates and in those with higher peripheral neutrophils count. Frozen-section biopsy positivity correlated with FFPE findings for fungi detection (p-value < 0.0001), with a sensitivity of 90.6%, specificity of 72.7%, and accuracy of 86.0%.

Conclusion

Implementation of this standardized protocol was related to a considerably low mortality rate among patients with suspected AIFRS at our Institution. Frozen-section biopsy revealed high accuracy to diagnose AIFRS. The current protocol including frozen-tissue biopsy improved the evaluation and survival rates of immunocompromised patients with presumed AIFRS.

Correlation Between β-Glucan and Neutrophil/Eosinophil Ratio of Paranasal Sinus Mucosa and Blood in the Diagnosis of Chronic Fungal Rhinosinusitis

Objectives

Chronic fungal rhinosinusitis is a major health problem because of the large impact on quality of life and difficult medical treatment. Its prevalence is increasing. There is currently an opportunity to establish the diagnosis without invasive intervention by utilizing β-glucan, which is the largest component of fungal cell wall and neutrophil/eosinophil ratio (NER). We sought to discover the correlation between β-glucan level and the NER of paranasal sinuses mucosa and blood as a potential diagnostic marker for patients with chronic fungal rhinosinusitis.

Methods

We conducted a cross-sectional study involving 20 subjects. Blood sampling and maxillary sinus surgery were performed, and fungal identification in the sinus mucosa was determined using the polymerase chain reaction. If a fungal species with β-glucan was found, then the examination was continued with the measurement of β-glucan by enzyme-linked immunosorbent assay, neutrophil, and eosinophil flow cytometry in sinus mucosa and blood.

Results

Aspergillus flavus is the most commonly found fungus. All subjects passed the positive β-glucan limit (³ 80 pg/mL) of the mucosal sample and only one subject had intermediate results (60-79 pg/mL) from their blood sample. Seventeen subjects had mucosal eosinophilic inflammation whereas the blood of 12 subjects revealed neutrophilic inflammation. There was no significant difference between the level of β-glucan in blood and mucosal sinus (p = 0.886), so that β-glucan examination of blood can describe β-glucan levels in paranasal sinuses. There was a significant difference between mucosal NER and blood (p < 0.001). β-glucan level with NER in both paranasal sinus mucosa and blood had no significant correlation (p > 0.050).

Conclusions

β-glucan can be used to establish the diagnosis of chronic fungal rhinosinusitis. However, differential diagnosis of allergy or infection cannot be excluded by examination of blood NER. Still, it is hoped that the process of diagnosis can be obtained quickly and precisely without the need for invasive procedure although it requires more research, especially related to the diagnostic test.

Sinonasal Mucormycosis: A to Z

Mucormycosis caused by one of the members of Mucoraceae family, is one of the most rapidly spreading and fatal fungal infection occurring mostly in Diabetic or Immunocompromised patients especially in developing countries. 26 patients suffering from sinonasal mucormycosis admitted in SGRRIM&HS, Dehradun from January 2013 to January 2017 are discussed. Diagnosis of mucormycosis was established on strong clinical suspicion with presence of grayish black crusting on nasal endoscopy which is confirmed by histopathology examination. Immediate correction of underlying immunocompromised status with debridement with intravenous liposomal amphotericin B was done in all the 26 cases out of which 10 patients were cured. Early detection and aggressive multidisciplinary management is must for the successful treatment of mucormycosis.

Evidence for a 'preinvasive' variant of fungal sinusitis: Tissue invasion without angioinvasion

Clinical experience has suggested the existence of an intermediate form of fungal sinusitis between the categories of non-invasive fungal sinusitis (non-IFS) and invasive fungal sinusitis (IFS). This fungal sinusitis variant demonstrates unhealthy mucosa by endoscopy with fungal invasion, but lacks angioinvasion microscopically, representing what clinically behaves as a 'pre-invasive' subtype of fungal sinusitis. Unlike non-IFS disease, patients with pre-invasive fungal sinusitis were still felt to require anti-fungal medications due to histologic presence of invasive fungus. While sharing some clinical features of IFS, these 'intermediate' patients were successfully spared extended and repeated surgical debridements given the microscopic findings, and have been successfully treated with shorter courses of antifungal therapy. These select patients have had favorable outcomes when managed in a judicious and semi-aggressive manner, in an undefined zone between the treatments for routine fungal ball and aggressive IFS.

The spectrum of allergic fungal diseases of the upper and lower airways

Fungi cause a wide spectrum of fungal diseases of the upper and lower airways. There are three main phyla involved in allergic fungal disease: (1) Ascomycota (2) Basidiomycota (3) Zygomycota. Allergic fungal rhinosinusitis (AFRS) causes chronic rhinosinusitis symptoms and is caused predominantly by Aspergillus fumigatus in India and Bipolaris in the United States. The recommended treatment approach for AFRS is surgical intervention and systemic steroids. Allergic bronchopulmonary aspergillosis (APBA) is most commonly diagnosed in patients with asthma or cystic fibrosis. Long term systemic steroids are the mainstay treatment option for ABPA with the addition of an antifungal medication. Fungal sensitization or exposure increases a patient's risk of developing severe asthma and has been termed severe asthma associated with fungal sensitivity (SAFS). Investigating for triggers and causes of a patient's asthma should be sought to decrease worsening progression of the disease.

Chronic invasive fungal sinusitis associated with intranasal drug use

Chronic invasive fungal sinusitis (CIFS) is a rare but potentially aggressive form of invasive fungal disease that occurs in immunocompetent patients. We report a case of CIFS in an otherwise healthy young adult associated with intranasal illicit drug abuse. The patient presented with nonhealing nasal septal and palatal perforations. Biopsy demonstrated invasive Aspergillus flavus requiring surgical debridement and extended intravenous antifungal therapy. Tissue necrosis and ulceration related to intranasal drug use should be recognized as a potential risk factor for invasive fungal sinusitis.

Cochliobolus hawaiiensis Sinusitis, a Tropical Disease? A Case Report and Review of the Literature

A sinusitis caused by Cochliobolus hawaiiensis (anamorph: Bipolaris hawaiiensis) was diagnosed in metropolitan France in a patient originating from New Caledonia. The patient completely recovered after surgical treatment consisting in marsupialization of the mucoceles and removal of the fungus balls located in the left nasal cavity and the left maxilla and ethmoid sinuses. One year after, both endoscopic examination and CT scan of the sinuses were normal. Various clinical presentations of diseases associated with C. hawaiiensis have been reported. A review of the literature indicates that although C. hawaiiensis is very rarely reported in Europe, it is one of the major rhinosinusitis agents in areas with a relatively warmer climate, such as India or Southwestern USA. This is the first report of a sinusitis caused by C. hawaiiensis diagnosed in France, with a total recovery outcome.

Impact of treatment time on the survival of patients suffering from invasive fungal rhinosinusitis

BACKGROUND

Invasive fungal rhinosinusitis is an uncommon disease with high mortality rates. There is currently no consensus on the best treatment timing. We studied the impact of the treatment timing on the survival of patients experiencing invasive fungal rhinosinusitis.

METHODS

We conducted a retrospective study of patients suffering from invasive fungal rhinosinusitis. The duration of symptoms, clinical presentations, clinical signs, diagnoses, treatments, and outcomes were collected.

RESULTS

It was observed that more than 70% of the mortalities occurred within the subgroup of patients who exhibited symptoms of the disease within 14 days before admission.

After adjusting for the confounders, the time taken to treat the patients was the most statistically significant predictor for mortality (P = 0.045). We found no significant relationships between mortality and its significant covariates, which included the underlying diseases (P = 0.91) or complications (P = 0.55).

CONCLUSIONS

Our study demonstrates that the time taken to treat the patients is an important determinant for the survival of patients who are afflicted with invasive fungal rhinosinusitis. The appropriate treatments should be administered within 14 days from the time the symptoms begin to manifest.

Invasive fungal rhinosinusitis versus bacterial rhinosinusitis with orbital complications: a case-control study

BACKGROUND

Invasive fungal rhinosinusitis with orbital complications (IFSwOC) is a life-threatening condition. The incidence of mortality has been reported to be up to 80 percent. This study was conducted to determine the risk factors, presentations, clinical, and imaging findings that could help to manage this condition promptly.

METHODS

We conducted a case-control study of 100 patients suffering from rhinosinusitis with orbital complications. The risk factors, clinical presentations, radiological findings, medical and surgical managements, durations of hospital stay, and mortality rate data were collected.

RESULTS

Sixty-five patients were diagnosed with IFSwOC, while the other thirty-five patients composed the control group. The most important risk factor for IFSwOC was diabetes mellitus. Visual loss and diplopia were the significant symptom predictors. The significant clinical predictors were nasal crust, oculomotor nerve, and optic nerve involvement. The CT findings of IFSwOC were sinus wall erosion and hyperdensity lesions. The mortality rate was 25.71 percent in the IFSwOC group and 3.17 percent in the control group.

CONCLUSIONS

Invasive fungal rhinosinusitis with orbital complications is symptomatic of a high mortality rate. The awareness of a patient's risk factors, the presenting symptoms, signs of fungal invasion, and aggressive management will determine the success of any treatment procedures.

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.

Fungal disease of the nose and sinuses: an updated overview

Fungal diseases of the nose and sinuses encompasses a diverse spectrum of disease. Clinical manifestations are largely dependent upon the immune status of the host, as, given the ubiquitous nature of these organisms, exposure is unavoidable. Asymptomatic colonization of the nasal passages by fungi warrants no treatment and is common, while allergic fungal rhinosinusitis is challenging and often requires a combined approach of surgical intervention, immunotherapy, and corticosteroid administration. A diagnosis requires a combination of IgE immune reactivity, eosinophilic infiltration, and fungi recovery. Similarly, invasive disease may present only after several months of slowly progressive disease, or in rapid and fulminant fashion in the appropriate host. A differentiation of these overlapping syndromes and the pathophysiologic processes at play, and recommended treatment algorithms, are the focus of this review.

Cervicofacial tissue infarction in patients with acute invasive fungal sinusitis: prevalence and characteristic MR imaging findings

INTRODUCTION

Tissue infarction is known as one of the characteristic features of invasive fungal sinusitis (IFS). The purpose of this study was to investigate the prevalence and characteristic MR imaging findings of cervicofacial tissue infarction (CFTI) associated with acute IFS.

METHODS

We retrospectively reviewed MR images in 23 patients with histologically or microbiologically proven acute IFS. CFTI was defined as an area of lack of enhancement in and around the sinonasal tract on contrast-enhanced T1-weighted images. We divided CFTI into two groups, i.e., intrasinonasal and extrasinonasal. Particular attention was paid to the location of extrasinonasal CFTI and the signal intensity of CFTI on T1- and T2-weighted images. The presence of bone destruction on CT scans was also recorded.

RESULTS

CFTI was found in 17 (74%) of 23 patients. All of these 17 patients had intrasinonasal CFTI, and 13 patients also had extrasinonasal CFTI. All 13 patients with extrasinonasal CFTI died of disease directly related to IFS. Various locations were involved in the 13 patients with extrasinonasal CFTI, including the orbit (n = 8), infratemporal fossa (n = 7), intracranial cavity (n = 3), and oral cavity and/or facial soft tissue (n = 4). Various signal intensities were noted at the area of CFTI on T1- and T2-weighted images. Bone destruction was found on CT scans in only 3 of 17 patients with CFTI.

CONCLUSION

CFTI with preservation of the bony wall of the involved sinonasal tract may be a characteristic MR imaging finding of acute IFS. The mortality is very high once the lesion extends beyond the sinonasal tract.

Sinonasal risk factors for the development of invasive fungal sinusitis in hematological patients: Are they important?

Invasive fungal sinusitis (IFS) is a highly aggressive infection that can affect hematologic patients. The classically described general risk factors, however, do not fully explain the development of IFS in a small percentage of cases. This study examined the impact of anatomic sinonasal factors and environmental factors on the development of IFS in high-risk patients. Medical records and computed tomography (CT) scans of patients admitted to our institution who were at high risk of developing IFS were retrospectively reviewed. Twenty-seven patients of 797 fulfilled the inclusion criteria. Patients affected by IFS were compared with patients not affected to identify possible sinonasal and environmental risk factors of IFS. Seven patients were excluded because of the lack of adequate radiological images. Six of the 20 eligible patients were assigned to the study group of patients affected by IFS and the remaining 14 patients were assigned to the control group. All but one case developed the infection during the summer with a significantly higher mean environmental temperature (p = 0.002). Anatomic nasal alterations were found in all patients affected by IFS and were significantly more frequent than in the control group (p = 0.014). It would be advisable to have patients with hematologic risk factors of IFS, especially during the summer period, undergo endoscopic nasal assessment. Furthermore, a CT finding of anatomic nasal alterations, such as anterior nasal septum deviation causing nasal obstruction, should increase the suspicion of IFS in case of the occurrence of nasal symptoms.

Acute versus Chronic Invasive Fungal Rhinosinusitis: A Case-Control Study

Introduction

Invasive fungal rhinosinusitis is a challenging condition that can be found mostly in immunocompromised patients. Failure to diagnose and treat this entity promptly usually results in rapid progression and death. The purpose of this study was to determine clinical presentation, complication and morbidity in patients with acute versus chronic invasive fungal rhinosinusitis.

Setting and design

Case-control study at Srinagarind Hospital, Khon Kaen University between January 1998 and May 2008.

Methods

The patient's data with the diagnosis of invasive fungal rhinosinusitis was included. Demographic data, underlying diseases, presenting symptoms, histologic sinonasal tissue evaluations, sinonasal tissue cultures, CT scan findings, surgical interventions, morbidity, and mortality were collected.

Results

Sixty-five patients were diagnosed as invasive fungal rhinosinusitis between January 1998 and May 2008. The data of six patients were unable to obtain. Fifty-nine patients were included in this study. Patients with immunocompromised status have significant greater risk for acute than chronic IFS, OR = 6.5 ( P = 0.004). Patients with mucosal necrosis have the significant higher risk for acute IFS, OR = 5.5 ( P = 0.01). There was no significant difference in orbital complications proportion between acute and chronic invasive fungal rhinosinusitis, OR = 2.42 ( P = 0.15). Sinus wall erosion have found significantly in chronic IFS group, OR = 0.24 ( P = 0.02). The average hospital stayed was 30.58 ± 26.43 days with no difference between groups ( P = 0.50). Fourteen patients in acute IFS group were dead (31.11%) while all patients in chronic IFS group were survived.

Conclusions

Invasive fungal rhinosinusitis continues to present a challenge to the otolaryngologist. Acute IFS was found most commonly in immunocompromised patients. The most consistent finding of acute IFS was mucosal necrosis and black crust/debris. The CT finding of sinus wall erosion may help in diagnosis of chronic IFS.

Fungal disease of the nose and paranasal sinuses

Fungal infections of the nose and paranasal sinuses represent a spectrum of diseases ranging from colonization to invasive rhinosinusitis. Clinical manifestations are largely dependent on the immune status of the host, and given the ubiquitous nature of these organisms, exposure is unavoidable. Noninvasive disease includes asymptomatic fungal colonization, fungus balls, and allergic fungal rhinosinusitis. Invasive disease includes indolent chronic rhinosinusitis, granulomatous fungal sinusitis, and acute fulminant fungal rhinosinusitis. A differentiation of these somewhat overlapping syndromes and the disparate treatment regimens required for effective management are the focus of this review.

Pediatric invasive sinonasal Scopulariopsis brevicaulis--a case report and literature review

OBJECTIVE

Acute invasive fungal sinusitis (AIFS) appears mainly in immunocompromized patients and may be caused by various pathogens. We describe a teenager with invasive sinonasal Scopulariopsis brevicaulis and review all the reports on this rare pathogen.

METHODS

A literature search on Scopulariopsis sinonasal invasive infections was performed and clinical data including age, gender, co-morbidities, treatment and prognosis was collected on all the patients.

RESULTS

A 17 years old boy with acute myelocytic leukemia and Scopulariopsis brevicaulis sinonasal infection was successfully treated at our department with a combination of extensive surgical debridement and antifungal antibiotics. We found six articled describing six patients with AIFS due to Scopulariopsis species. Four patients were adults and two were children, 3 males and 3 females. Two had an infection with Scopulariopsis acremoium, one with Scopulariopsis candida and for 3 patients no data was given on the specific Scopulariopsis species. All the patients except one were immunocompromized. One patient was treated with antifungal drugs, 2 with surgery and 4 patients received antifungals and were operated. One patient died due to the fungal infection and two patients died due to other causes.

CONCLUSIONS

Scopulariopsis AIFS is a life threatening disease affecting mainly immunocompromized patients, both children and adults. No clear treatment regimen has been established yet. We describe the first case of a teenager with Scopulariopsis brevicaulis sinonasal infection treated successfully with a combination of wide local excision and antifungal therapy.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses

In this review, anatomy and physiology of the respiratory mucosa of nose and paranasal sinuses are summarized under the aspect of its clinical significance. Basics of endonasal cleaning including mucociliary clearance and nasal reflexes, as well as defence mechanisms are explained. Physiological wound healing, aspects of endonasal topical medical therapy and typical diagnostic procedures to evaluate the respiratory functions are presented. Finally, the pathophysiologies of different subtypes of non-allergic rhinitis are outlined together with treatment recommendations.

Inflammatory diseases of the nasal cavities and paranasal sinuses

Inflammatory diseases of the nose and paranasal sinus are commonly encountered in diagnostic histopathology. This review describes the possible manifestations of the common diseases as well as highlighting some of the uncommon causes of sinonasal inflammation which may have importance for treatment and prognosis. The diagnosis of fungal sinusitis is primarily histological. It is important to distinguish between invasive and non-invasive fungal sinusitis, the latter including allergic fungal sinusitis characterized by 'allergic mucin' and scanty fungal hyphae. Nasal eosinophilia is a feature of both allergic and non-allergic rhinosinusitis and a wide range of secondary changes in inflammatory polyps may lead to diagnostic confusion. Nasal biopsies are often taken from perforations or inflammatory masses to confirm or exclude granulomatous diseases. There is a broad differential diagnosis for granulomatous sinonasal disease and pathologists should appreciate the diagnostic histological and clinical features of these conditions.