Fungus culture and PCR in nasal lavage samples of patients with chronic rhinosinusitis

Immunopathologic Role of Fungi in Chronic Rhinosinusitis

Airborne fungi are ubiquitous in the environment and are commonly associated with airway inflammatory diseases. The innate immune defense system eliminates most inhaled fungi. However, some influence the development of chronic rhinosinusitis. Fungal CRS is thought of as not a common disease, and its incidence increases over time. Fungi are present in CRS patients and in healthy sinonasal mucosa. Although the immunological mechanisms have not been entirely explained, CRS patients may exhibit different immune responses than healthy people against airborne fungi. Fungi can induce Th1 and Th2 immune responses. In CRS, Th2-related immune responses against fungi are associated with pattern recognition receptors in nasal epithelial cells, the production of inflammatory cytokines and chemokines from nasal epithelial cells, and interaction with innate type 2 cells, lymphocytes, and inflammatory cells. Fungi also interact with neutrophils and eosinophils and induce neutrophil extracellular traps (NETs) and eosinophil extracellular traps (EETs). NETs and EETs are associated with antifungal properties and aggravation of chronic inflammation in CRS by releasing intracellular granule proteins. Fungal and bacterial biofilms are commonly found in CRS and may support chronic and recalcitrant CRS infection. The fungal-bacterial interaction in the sinonasal mucosa could affect the survival and virulence of fungi and bacteria and host immune responses. The interaction between the mycobiome and microbiome may also influence the host immune response, impacting local inflammation and chronicity. Although the exact immunopathologic role of fungi in the pathogenesis of CRS is not completely understood, they contribute to the development of sinonasal inflammatory responses in CRS.

Nasal Mycology of Chronic Rhinosinusitis Revealed by Nanopore Sequencing

Background: Nanopore sequencing (NS) is a third-generation sequencing technology capable of generating reads of long sequences. In this study, we used NS to investigate nasal mycology in patients with chronic rhinosinusitis (CRS). Methods: Nasal cavities of 13 CRS patients were individually irrigated with 20 mL of distilled water. The irrigant was forcefully blown by the patient into a basin. The collected fluid was placed into a centrifuge tube and processed using the method of Ponikau et al. The collected specimens were used for traditional fungal culture and sequenced for total DNA using NS. Results: Traditional fungal culture successfully grew fungi in the specimens of 11 (84.6%) patients. Aspergillus sp. and Penicillium sp. were found in four (30.8%) patients, Cladosporium sp. in three (23.1%) patients, and Candida albicans, Mucor sp. and Chaetomium sp. in one patient. NS revealed fungi abundance ranged from 81 to 2226, with the Shannon species diversity ranging from 1.094 to 1.683 at the genus level. Malassezia sp. was sequenced in 13 patients, Aspergillus sp. in 12 (92.3%) patients, Candida albicans in 11 (84.6%) patients, and Penicillium sp. in 10 (76.9%) patients. Conclusion: Our results showed that NS was sensitive and fast in detecting nasal fungi in CRS patients.

Comparison of Subtyping Approaches and the Underlying Drivers of Microbial Signatures for Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a major human health problem that significantly reduces quality of life. While various microbes have been implicated, there is no clear understanding of the role they play in CRS pathogenesis. Another equally important observation made for CRS patients is that the epithelial barrier in the sinonasal cavity is defective. Finding a robust approach to subtype CRS patients would be the first step toward unravelling the pathogenesis of this heterogeneous condition. Previous work has explored stratification based on the clinical presentation of the disease (with or without polyps), inflammatory markers, pathology, or microbial composition. Comparisons between the different stratification approaches used in these studies have not been possible due to the different cohorts, analytical methods, or sample sites used. In this study, two approaches for subtyping CRS patients were compared, and the underlying drivers of the heterogeneity in CRS were also explored.

Chronic rhinosinusitis (CRS) is a heterogeneous condition characterized by persistent sinus inflammation and microbial dysbiosis. This study aimed to identify clinically relevant subgroups of CRS patients based on distinct microbial signatures, with a comparison to the commonly used phenotypic subgrouping approach. The underlying drivers of these distinct microbial clusters were also investigated, together with associations with epithelial barrier integrity. Sinus biopsy specimens were collected from CRS patients (n = 23) and disease controls (n = 8). The expression of 42 tight junction genes was evaluated using quantitative PCR together with microbiota analysis and immunohistochemistry for measuring mucosal integrity and inflammation. CRS patients clustered into two distinct microbial subgroups using probabilistic modelling Dirichlet (DC) multinomial mixtures. DC1 exhibited significantly reduced bacterial diversity and increased dispersion and was dominated by Pseudomonas, Haemophilus, and Achromobacter. DC2 had significantly elevated B cells and incidences of nasal polyps and higher numbers of Anaerococcus, Megasphaera, Prevotella, Atopobium, and Propionibacterium. In addition, each DC exhibited distinct tight junction gene and protein expression profiles compared with those of controls. Stratifying CRS patients based on clinical phenotypic subtypes (absence or presence of nasal polyps [CRSsNP or CRSwNP, respectively] or with cystic fibrosis [CRSwCF]) accounted for a larger proportion of the variation in the microbial data set than with DC groupings. However, no significant differences between CRSsNP and CRSwNP cohorts were observed for inflammatory markers, beta-dispersion, and alpha-diversity measures. In conclusion, both approaches used for stratifying CRS patients had benefits and pitfalls, but DC clustering provided greater resolution when studying tight junction impairment. Future studies in CRS should give careful consideration to the patient subtyping approach used.

IMPORTANCE Chronic rhinosinusitis (CRS) is a major human health problem that significantly reduces quality of life. While various microbes have been implicated, there is no clear understanding of the role they play in CRS pathogenesis. Another equally important observation made for CRS patients is that the epithelial barrier in the sinonasal cavity is defective. Finding a robust approach to subtype CRS patients would be the first step toward unravelling the pathogenesis of this heterogeneous condition. Previous work has explored stratification based on the clinical presentation of the disease (with or without polyps), inflammatory markers, pathology, or microbial composition. Comparisons between the different stratification approaches used in these studies have not been possible due to the different cohorts, analytical methods, or sample sites used. In this study, two approaches for subtyping CRS patients were compared, and the underlying drivers of the heterogeneity in CRS were also explored.

Identification of fungal causative agents of rhinosinusitis from Mashhad, Iran

Background and Purpose:

Rhinosinusitis is a common disorder, influencing approximately 20% of the population at some time of their lives. It was recognized and reported with expanding recurrence over the past two decades worldwide. Undoubtedly, correct diagnosis of fungi in patients with fungal rhinosinusitis affects the treatment planning and prognosis of the patients. Identification of the causative agents using the standard mycological procedures remains difficult and time-consuming.

Materials and Methods:

Based on clinical and radiological parameters, 106 patients suspected of fungal rhinosinusitis were investigated in this cross-sectional prospective study from April 2012 to March 2016 at an otorhinolaryngology department. In this study, internal transcribed spacer (ITS) and calmodulin (CaM) sequencing were respectively validated as reliable techniques for the identification of Mucorales and Aspergillus to species level (both agents of fungal rhinosinusitis).

Results:

Of these, 63 (59.4%) patients were suspected of allergic fungal rhinosinusitis (AFRS), 40 (37.7%) patients suspected of acute invasive fungal rhinosinusitis (AIFRS), and 3 (2.8%) patients suspected of mycetoma. In patients suspected of AFRS, AIFRS, and mycetoma only 7, 29, and 1 had positive fungal culture, respectively. After ITS and CaM sequencing, Aspergillus flavus was the most common species isolated from non-invasive forms, and A. flavus and Rhizopus oryzae were more frequently isolated from invasive forms.

Conclusion:

Aspergillus flavus is the most common agent of fungal rhinosinusitis in Iran, unlike most other reports from throughout the world stating that A. fumigatus is the most frequent causative agent of this disease.

Diagnosis, classification, and therapeutic interventions for sinopulmonary Aspergillosis

INTRODUCTION

Sinopulmonary aspergillosis represents a diverse collection of allergic, invasive, and chronic sinus and respiratory conditions. These diseases can affect patients with and without immune impairment and in some cases may be life-threatening. Areas covered: We review the diagnosis, classification, and therapeutic options available to treat sinopulmonary aspergillosis and look ahead to emerging diagnostic and therapeutic options that may soon play an important role in clinical practice. Expert commentary: Histopathology and tissue culture remain the gold standard for the diagnosis of invasive sinopulmonary aspergillosis, but several new molecular detection methods have recently emerged, including various PCR-based platforms, MALDI-TOF, and lateral flow assays. We examine these methodologies as well as the barriers associated with the standardization, validation, and implementation. We also explore the pipeline of antifungal agents in development to treat sinopulmonary aspergillosis.

Allergic Aspergillus Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a unique variety of chronic polypoid rhinosinusitis usually in atopic individuals, characterized by presence of eosinophilic mucin and fungal hyphae in paranasal sinuses without invasion into surrounding mucosa. It has emerged as an important disease involving a large population across the world with geographic variation in incidence and epidemiology. The disease is surrounded by controversies regarding its definition and etiopathogenesis. A working group on "Fungal Sinusitis" under the International Society for Human and Animal Mycology (ISHAM) addressed some of those issues, but many questions remain unanswered. The descriptions of "eosinophilic fungal rhinosinusitis" (EFRS), "eosinophilic mucin rhinosinusitis" (EMRS) and mucosal invasion by hyphae in few patients have increased the problem to delineate the disease. Various hypotheses exist for etiopathogenesis of AFRS with considerable overlap, though recent extensive studies have made certain in depth understanding. The diagnosis of AFRS is a multi-disciplinary approach including the imaging, histopathology, mycology and immunological investigations. Though there is no uniform management protocol for AFRS, surgical clearing of the sinuses with steroid therapy are commonly practiced. The role of antifungal agents, leukotriene antagonists and immunomodulators is still questionable. The present review covers the controversies, recent advances in pathogenesis, diagnosis, and management of AFRS.

Contribution of molecular tools for the diagnosis and epidemiology of fungal chronic rhinosinusitis

Chronic rhinosinusitis (CRS) rank second at chronic inflammatory diseases in industrialized countries and are an important public health concern. Diagnosis relies on a set of arguments including clinical signs, imaging, histopathologic and mycological analyses of sinus specimens, collected during nasal endoscopy. The sensitivity of fungal cultures is reported to be poor, even when direct examination is positive, thus the epidemiology of fungal chronic sinusitis is ill-known. This study evaluated the sensitivity of molecular diagnosis in 70 consecutive samples (61 patients with CRS) analysed at the University Hospital of Rennes during a 3-year period. DNA detection was performed using a conventional PCR method targeting the ITS1/ITS2 sequence and the resulting amplification products were sequenced. Fungal CRS was proven in 42 patients (69%), of which only 20 (48%) had a positive culture. 37/42 (88%) patients were diagnosed with a fungus ball, 3 with allergic fungal CRS and 2 with undetermined fungal CRS. PCR was positive in all 42 cases and direct sequencing allowed to identify fungi in all cases but one, and detected multiple infection in 3. Aspergillus fumigatus was present in 69% of patients; Cladosporium cladosporoides in 9.5%, Scedosporium sp., A. nidulans and A. flavus in 7% each. In 2/19 patients with negative direct examination, sequencing analysis revealed the presence of Capnobotryella sp. and C. cladosporoides, in clinical settings compatible with fungal sinusitis. In conclusion, ITS1/ITS2 PCR had a twice better sensitivity than culture, and combined sequencing provides accurate epidemiological data on fungal CRS.

Epidemiology and differential diagnosis of nasal polyps

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common chronic medical conditions, with a significant impact on patient quality of life. CRS is broadly classified into two groups: CRS with nasal polyposis (CRSwNP) and CRS without NP (CRSsNP). Clinically, the major subtypes of CRSwNP may be divided into eosinophilic chronic rhinosinusitis (e.g., allergic fungal rhinosinusitis and aspirin-exacerbated respiratory disease [AERD]) and nasal polyps associated with neutrophilic inflammation (e.g., cystic fibrosis [CF]). CF is characterized by mutation of the gene encoding the CF transmembrane conductance regulator. Functional endoscopic sinus surgery is usually required for most NP patients with increased frequency in patients with AERD. This study provides a review of the epidemiology and major classification of CRSwNP.

METHODS

A review was performed of the literature regarding different subtypes of CRSwNP.

RESULTS

Many definitions of CRSwNP exist and estimates of prevalence vary.

CONCLUSION

CRSwNP is a clinical syndrome with a heterogeneous inflammatory profile. Of the subtypes associated with eosinophilic inflammation, AERD remains the most recalcitrant to medical and surgical therapeutic interventions.

Pretreatment of sinus aspirates with dithiothreitol improves yield of fungal cultures in patients with chronic sinusitis

BACKGROUND

Mold pathogens are a leading cause of chronic rhinosinusitis. Successful isolation of mold on culture is helpful in establishing a diagnosis and guiding therapy. Though mucolytic agents are commonly used in European countries, they are not part of everyday use in North America. In this case-control prospective study, we investigated the yield of fungal culture before and after treatment of sinus aspirates with the mucolytic agent dithiothreitol in a United States hospital.

METHODS

Over a 5-month period during 2011-2012, 359 sinus aspirates from 294 patients with symptoms suspicious for chronic sinusitis or allergic fungal sinusitis were collected. Aspirates were cultured on fungal medium before and after treatment with dithiothreitol.

RESULTS

Of the 359 pairs of cultures, 62 (17.3%) demonstrated mold growth on at least 1 of the plates, 9 (14.5%) of which grew more than 1 species of mold. A total of 75 molds were identified, 41 (54.7%) of which were successfully cultured only when the mucus was pretreated with dithiothreitol (p < 0.0001). Quantitatively, more colonies grew from dithiothreitol-treated mucus than from direct-inoculation (p < 0.0001).

CONCLUSION

This study confirms improved recovery of mold from sinus cultures after pretreatment of samples with dithiothreitol. Further studies are needed to correlate these findings with clinical outcome.

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.

The role of fungi in diseases of the nose and sinuses

BACKGROUND

Human exposure to fungal elements is inevitable, with normal respiration routinely depositing fungal hyphae within the nose and paranasal sinuses. Fungal species can cause sinonasal disease, with clinical outcomes ranging from mild symptoms to intracranial invasion and death. There has been much debate regarding the precise role fungal species play in sinonasal disease and optimal treatment strategies.

METHODS

A literature review of fungal diseases of the nose and sinuses was conducted.

RESULTS

Presentation, diagnosis, and current management strategies of each recognized form of fungal rhinosinusitis was reviewed.

CONCLUSION

Each form of fungal rhinosinusitis has a characteristic presentation and clinical course, with the immune status of the host playing a critical pathophysiological role. Accurate diagnosis and targeted treatment strategies are necessary to achieve optimal outcomes.

Current status and future perspectives on molecular and serological methods in diagnostic mycology

Invasive fungal infections are an important cause of infectious morbidity. Nonculture-based methods are increasingly used for rapid, accurate diagnosis to improve patient outcomes. New and existing DNA amplification platforms have high sensitivity and specificity for direct detection and identification of fungi in clinical specimens. Since laboratories are increasingly reliant on DNA sequencing for fungal identification, measures to improve sequence interpretation should support validation of reference isolates and quality control in public gene repositories. Novel technologies (e.g., isothermal and PNA FISH methods), platforms enabling high-throughput analyses (e.g., DNA microarrays and Luminex® xMAP™) and/or commercial PCR assays warrant further evaluation for routine diagnostic use. Notwithstanding the advantages of molecular tests, serological assays remain clinically useful for patient management. The serum Aspergillus galactomannan test has been incorporated into diagnostic algorithms of invasive aspergillosis. Both the galactomannan and the serum β-D-glucan test have value for diagnosing infection and monitoring therapeutic response.

Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies

BACKGROUND

Fungal (rhino-) sinusitis encompasses a wide spectrum of immune and pathological responses, including invasive, chronic, granulomatous, and allergic disease. However, consensus on terminology, pathogenesis, and optimal management is lacking. The International Society for Human and Animal Mycology convened a working group to attempt consensus on terminology and disease classification.

DISCUSSION

Key conclusions reached were: rhinosinusitis is preferred to sinusitis; acute invasive fungal rhinosinusitis is preferred to fulminant, or necrotizing and should refer to disease of <4 weeks duration in immunocompromised patients; both chronic invasive rhinosinusitis and granulomatous rhinosinusitis were useful terms encompassing locally invasive disease over at least 3 months duration, with differing pathology and clinical settings; fungal ball of the sinus is preferred to either mycetoma or aspergilloma of the sinuses; localized fungal colonization of nasal or paranasal mucosa should be introduced to refer to localized infection visualized endoscopically; eosinophilic mucin is preferred to allergic mucin; and allergic fungal rhinosinusitis (AFRS), eosinophilic fungal rhinosinusitis, and eosinophilic mucin rhinosinusitis (EMRS) are imprecise and require better definition. In particular, to implicate fungi (as in AFRS and EMRS), hyphae must be visualized in eosinophilic mucin, but this is often not processed or examined carefully enough by histologists, reducing the universality of the disease classification. A schema for subclassifying these entities, including aspirin-exacerbated rhinosinusitis, is proposed allowing an overlap in histopathological features, and with granulomatous, chronic invasive, and other forms of rhinosinusitis. Recommendations for future research avenues were also identified.

Acute fungal sinusitis: natural history and the role of frozen section

Acute fungal sinusitis is a life-threatening infection affecting immunocompromised patients. Historically, the most commonly recovered fungi are Aspergillus and Mucor. The extent of potentially disfiguring debridement surgery is grossly determined by the appearance of bleeding at the margins, signifying viable tissue and the absence of fungus. Requests for frozen section may concern the initial diagnosis and the intraoperative verification of margin status. In 12 patients with acute fungal sinusitis, frozen section was used in 8. Routine H&E stains demonstrated fungal hyphae in necrotic debris in 5 cases, often associated with vascular and perineural invasion. All patients underwent extensive sinus debridement, including orbital exenteration in 2 cases. All 12 patients died, 9 of fungal sepsis. Autopsy in 3 patients showed pulmonary involvement (2 cases), intracranial spread (1 case), and no residual fungus (1 case). Inexperience with organism recognition is surmountable. Frozen section has a role in the management of this devastating disease.

Fungus as the cause of chronic rhinosinusitis: the case remains unproven

PURPOSE OF REVIEW

To review the literature on the role of fungi in chronic rhinosinusitis (CRS) pathogenesis and the effect of antifungal drug therapy and antifungal immunotherapy.

RECENT FINDINGS

This paper reviews the most recent articles investigating the role of fungi in CRS pathogenesis. In addition to possible aberrant innate and adaptive antifungal immune responses and fungus antihost effects, which all may explain disease development, the effect of antifungal drug therapy and antifungal immunotherapy is reviewed.

SUMMARY

Although fungi can be detected in the nose and paranasal sinuses of nearly all patients with CRS and are present in almost all healthy controls, various studies suggest that there may be mechanisms by which fungi exert an effect on sinus mucosa in susceptible individuals only. Future studies will have to clarify the role of fungi in CRS, which fungal organisms, if at all, may be pathogenic and what exactly characterizes the immunological response to fungi that potentially results in the development of disease. Presently, in the absence of convincing immunological data and evidence for clinical improvement of CRS upon therapy with antifungal agents, the case against the fungus remains unproven.

The mold conundrum in chronic hyperplastic sinusitis

The role of fungi in chronic rhinosinusitis (CRS) is not clear. Fungi can be detected in the nose and paranasal sinuses of virtually all CRS patients; however, they also appear to be present in healthy controls. Various theories attempt to explain the mechanisms by which fungi can exert an effect on sinus mucosa in susceptible individuals. Further studies are necessary to clarify the role of fungi in CRS, which fungal organisms (if any) are pathogenic, and what exactly characterizes the immunologic response to fungi that may result in the development of disease. However, in the absence of convincing immunologic data and evidence of clinical improvement of CRS after antifungal therapy, the case against the fungus remains unproven.

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.

Staphylococcus aureus in nasal lavage and biopsy of patients with chronic rhinosinusitis

BACKGROUND

Staphylococcus aureus may play a relevant etiologic role in chronic rhinosinusitis (CRS) and may explain the T(H2) shift observed in CRS with nasal polyps (CRSNP(+)). Naturally occurring S. aureus small colony variants (SASCV) escape immune surveillance, antibiotic treatment and microbiologic routine diagnostic techniques. The frequency of S. aureus and SASCV in CRS patients and S. aureus-related effects on the local immune response should be prospectively investigated.

METHODS

Nasal lavages and mucosal biopsies of CRS patients were examined with bacterial culture suitable for detecting SASCV, real time PCR and fluorescence in situ hybridization. To assess the effects of S. aureus positivity, interleukin-5 (IL-5), interferon-gamma, total immunoglobulin E (IgE), eotaxin, granulocyte-colony stimulating factor, and eosinophil cationic protein in nasal lavages were determined and gene transcription analysis of nasal biopsies from S. aureus positive and negative CRSNP(+) patients was performed.

RESULTS

Thirty-one CRSNP(+) patients, 13 CRS patients without polyps, and 21 control patients were evaluated. Staphylococcus aureus was detected by any method in 25 patients (39%). Staphylococcus aureus detection rates did not differ between the three disease groups (P = 0.3). Staphylococcus aureus small colony variants were not found. In nasal lavages, IL-5 and total IgE levels were higher in CRSNP(+) patients than in CRSNP(-) patients or controls (P < 0.05). Staphylococcus aureus positivity did not influence biomarker concentrations in nasal lavages. Genes for T(H2) cytokines were not differentially transcribed.

CONCLUSIONS

We could not observe a higher prevalence of S. aureus in CRS patients with or without nasal polyps than in controls. We could not substantiate that S. aureus intensifies the T(H2) shift in CRSNP(+) patients. Staphylococcus aureus small colony variants were not detected in any sample.

The mold conundrum in chronic rhinosinusitis: where do we stand today?

Chronic rhinosinusitis (CRS) is an inflammatory disorder affecting the nose and paranasal sinuses. Although bacteria have long been implicated as pathogens in most forms of CRS, fungi may be responsible for some forms. Several recent studies demonstrated that, under optimal conditions, fungi can be identified in the nose and paranasal sinuses of nearly every individual (including all CRS patients). An aberrant immune response to these ubiquitous fungi has been suggested to explain the development of CRS in some individuals. Several mechanisms requiring additional research, including adequate controls, have been proposed and are reviewed in this article. Although preliminary trials suggested that CRS signs and symptoms improve upon treatment with topical and oral antifungal agents, several double-blind, placebo-controlled trials demonstrated the contrary. In the absence of convincing immunologic data and evidence of clinical improvement upon therapy with antifungal agents, the case against fungi remains unproven.

Negative impact of Aspergillus galactomannan and DNA detection in the diagnosis of fungal rhinosinusitis

A proportion of patients with chronic rhinosinusitis, especially if nasal polyps are present, have a diagnosis of fungal rhinosinusitis. The diagnosis is difficult to establish because the symptoms and clinical and radiological signs are non-specific. Also current diagnostic methods, i.e. histology, fungal staining and culture, are insensitive. The performance of the Aspergillus galactomannan (GM) ELISA and real-time PCR for Aspergillus fumigatus mitochondrial DNA was evaluated for the detection of Aspergillus in sinus mucus samples from 25 patients with chronic rhinosinusitis with nasal polyposis. The results were compared with those from nasal lavage fluid from 19 healthy volunteers. Seven patients (28 %) were diagnosed as having fungal rhinosinusitis according to the presence of filaments in histology or direct microscopy using Calcofluor white. All fungal rhinosinusitis patients were negative in the GM ELISA. GM ELISA was positive in five patients whose samples were negative using conventional methods and A. fumigatus PCR. Two out of seven patients with fungal rhinosinusitis were positive by A. fumigatus PCR: one also had a positive A. fumigatus culture, and one had hyphae consistent with Aspergillus in histology. One additional patient had a weak positive PCR result, but other fungal tests were negative. In control subjects, the GM ELISA was positive in 21 %, whereas direct microscopy, culture and A. fumigatus PCR were negative in all samples. Direct microscopy and culture together with histology remain pivotal in defining fungal rhinosinusitis diagnosis. A. fumigatus PCR may have additional value in allowing the diagnosis to be made sooner, whereas the GM ELISA is not reliable in diagnosing Aspergillus infection of the paranasal sinuses.

Nasal and sinus endoscopy for medical management of resistant rhinosinusitis, including postsurgical patients

Nasal endoscopy has been practiced by allergists since the early 1980s; however, allergists in general have not embraced endoscopic evaluation of patients with sinus disease, either before or after surgery. Allergists are in a unique position to render medical (as opposed to surgical) care of patients with sinusitis. There has been a growing realization that endoscopy is a valuable procedure for the evaluation and medical treatment of patients with difficult sinusitis. This has resulted in the need for a resource to allow allergists to understand the nature of endoscopic findings in patients with sinusitis, either preoperatively or postoperatively. This article introduces the findings at endoscopy that are common in patients with sinusitis, including those that may be seen after surgery. The findings include perforation of the septum, retained secretions, small surgical ostium caused by postoperative ostial stenosis, previous Caldwell Luc procedure, recirculation of mucus, hyperplastic nasal disease, synechiae, recurrent disease in previously unaffected sinuses, empty nose syndrome, frontal sinus disease, dental disease, and other, more complicated entities.

The role of fungi in the airway of chronic rhinosinusitis patients

PURPOSE OF REVIEW

To analyze the role of fungi in the upper and lower airway in chronic rhinosinusitis patients.

RECENT FINDINGS

Recently, the involvement of the lower airway (as asthma, small airway disease and bronchial hyperresponsiveness) in chronic rhinosinusitis patients had been documented. Fungal spores after inhalation are submerged in the aqueous lining layers of the airway. The site depends on the size of the inhaled spores. The process of inhalation, retention and clearance of fungal spores may explain the positive culture results in both normal subjects and in most chronic rhinosinusitis patients. Fungal culture of different parts of the upper and lower airway in chronic rhinosinusitis patients had no correlation with cellular changes (local eosinophilia) and other clinical parameters. In chronic rhinosinusitis, with persistence of the chronic inflammatory process, the cells may be activated nonspecifically.

SUMMARY

The role played by fungi in most chronic rhinosinusitis patients as the target antigen of initiation of such chronic inflammation is still debated. With the presence of chronic eosinophilic inflammation in chronic rhinosinusitis, an exaggerated reaction to various inhaled antigens is anticipated. The role of fungi will be confirmed only when T cells within the sinuses are shown to be actively responding to fungal antigens cultured from the sinus and with the demonstration that their elimination will stop the disease.

Fungal speciation using quantitative polymerase chain reaction (QPCR) in patients with and without chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objectives of this study were to determine the mycology of the middle meatus using an endoscopically guided brush sampling technique and polymerase chain reaction laboratory processing of nasal mucous; to compare the mycology of the middle meatus in patients with sinus disease with subjects without sinus disease; to compare the responses on two standardized quality-of-life survey forms between patients with and without sinusitis; and to determine whether the presence of fungi in the middle meatus correlates with responses on these data sets.

STUDY DESIGN

The authors conducted a single-blind, prospective, cross-sectional study.

METHODS

Patients with sinus disease and a control group without sinus disease were enrolled in the study. A disease-specific, validated Sinonasal Outcomes Test survey (SNOT-20) was completed by the subjects and a generalized validated Medical Outcomes Short Form 36 Survey (SF-36) was also completed. An endoscopically guided brush sampling of nasal mucous was obtained from the middle meatus. Fungal specific quantitative polymerase chain reaction (QPCR) was performed on the obtained sample to identify one of 82 different species of fungus in the laboratory. Statistical analysis was used to categorize the recovered fungal DNA and to crossreference this information with the outcomes surveys.

RESULTS

The fungal recovery rate in the study was 45.9% in patients with sinus disease and 45.9% in control subjects. Patients with chronic rhinosinusitis had a mean SNOT-20 score of 1.80 versus the control group mean score of 0.77 (P < .0001). SF-36 data similarly showed a statistically significant difference between diseased and control populations with controls scoring a mean of 80.37 and patients with chronic rhinosinusitis scoring a mean of 69.35 for a P value of .02. However, no statistical significance could be ascribed to the presence or absence of fungi recovered, the type of fungi recovered, or the possible impact of fungi on the quality-of-life survey results.

CONCLUSION

The recovery rate of fungi from the middle meatus of patients with chronic rhinosinusitis and a control population without chronic rhinosinusitis is 45.9% using QPCR techniques. No direct causation with regard to fungal species or presence was proven; however, a species grouping for future studies is proposed based on trends in this data and other reports. Disease-specific outcomes surveys revealed a statistically significant difference between the two groups.

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.

Canine chronic inflammatory rhinitis

Chronic inflammatory rhinitis is commonly found in dogs with chronic nasal disease and is characterized by lymphoplasmacytic infiltrates in the nasal mucosa in the absence of an obvious etiologic process. The pathogenesis of lymphoplasmacytic rhinitis remains unknown. Animals respond poorly to antibiotics, oral glucocorticoids, and antihistamines, making primary infectious, immune-mediated, or allergic etiologies unlikely. Aberrant immune response to inhaled organisms or allergens may induce inflammation in some animals. Common clinical signs include nasal discharge, sneezing, coughing, epistaxis, and stertor. Diagnosis is made by performing a thorough history, physical examination, radiography or advanced imaging (via computed tomography or magnetic resonance imaging), rhinoscopy, and nasal mucosal biopsy to rule out primary etiologies of nasal discharge. Treatment strategies have included various antibiotics, antihistamines, oral and inhalant steroids, nonsteroidal antiinflammatories, and antifungal medications. Some dogs may respond partially to doxycycline or azithromycin, although it is unclear whether response is related to antimicrobial or antiinflammatory properties of these drugs. Hydration of the nasal cavity through nasal drops or aerosols may limit nasal discharge, and some animals may improve with inhalant (but rarely oral) glucocorticoids.

Detection and quantification of Cladosporium in aerosols by real-time PCR

Cladosporium is one of the most common airborne molds found in indoor and outdoor environments. Cladosporium spores are important aeroallergens, and prolonged exposure to elevated spore concentrations can provoke chronic allergy and asthma. To accurately quantify the levels of Cladosporium in indoor and outdoor environments, two real-time PCR systems were developed in this study. The two real-time PCR systems are highly specific and sensitive for Cladosporium detection even in a high background of other fungal DNAs. These methods were employed to quantify Cladosporium in aerosols of five different indoor environments. The investigation revealed a high spore concentration of Cladosporium (10(7) m(-3)) in a cow barn that accounted for 28-44% of the airborne fungal propagules. In a countryside house that uses firewood for heating and in a paper and pulp factory, Cladosporium was detected at 10(4) spores m(-3), which accounted for 2-6% of the fungal propagules in the aerosols. The concentrations of Cladosporium in these three indoor environments far exceeded the medical borderline level (3000 spores m(-3)). In a power station and a fruit and vegetable storage, Cladosporium was found to be a minor component in the aerosols, accounted for 0.01-0.1% of the total fungal propagules. These results showed that monitoring Cladosporium in indoor environments is more important than in outdoor environments from the public health point of view. Cladosporium may not be the dominant fungi in some indoor environments, but its concentration could still be exceeding the threshold value for clinical significance. The methods developed in this study could facilitate accurate detection and quantification of Cladosporium for public health related risk assessment.