Clinical Features of Chronic Invasive Fungal Rhinosinusitis in 16 Cases

Chronic invasive fungal rhinosinusitis and granulomatous invasive fungal sinusitis: A systematic review of symptomatology and outcomes

INTRODUCTION

Chronic invasive fungal rhinosinusitis (CIFRS) and granulomatous invasive fungal sinusitis are two uncommon diseases differentiated primarily by the pathologic finding of non-caseating granulomas in GIFRS. Both share many similarities in presentation. We aim to characterize the symptomatology and outcomes of these diseases.

METHODS

A comprehensive search strategy was designed to identify studies in the Cochrane, EMBASE and PubMed databases from database inception to January 2022. Inclusion criteria included all patients with a diagnosis of either CIFRS or GIFRS. All studies were screened by two reviewers. Chi-square analyses were used where appropriate.

RESULTS

51 studies were included totaling 513 patients. The majority were diagnosed with CIFRS (389, 75.8 %) compared to GIFRS (124, 24.4 %). CIFRS was more common in immunocompromised or diabetic patients (p < 0.0001; p = 0.02). Patients with CIFRS were more likely to exhibit nasal symptoms including discharge (p = 0.0001), obstruction (p = 0.03) and congestion (p = 0.001) as well as systemic symptoms including fever, which no GIFRS patient exhibited, facial pain (p = 0.007), headache (p = 0.004). Aspergillus was the most common organism identified in both groups with a slight predominance among GIFRS patients (p = 0.01). GIFRS patients were also more likely to present with no identifiable organisms (p = 0.0006). CIFRS patients were more likely to die of disease (p = 0.0008).

CONCLUSIONS

CIFRS generally presents with more symptoms and is associated with poorer outcomes primarily occurring in an immunocompromised population. GIFRS likely follows a more insidious course in immunocompetent patients. Understanding the key differences in symptomatology and outcomes for these two populations is critical for appropriate diagnosis and prognostication.

Difficulty in management of acute invasive fungal rhinosinusitis in Indonesia during the COVID-19 pandemic: A case report

Invasive fungal rhinosinusitis is a rare disease with a high morbidity and mortality rate. Lately, COVID-19 has been associated with an increased incidence of this disease. We present the first case of COVID-19-associated acute invasive fungal rhinosinusitis found in Indonesia. The risk factors for the disease include corticosteroid use and antibiotic use. The case was complicated with left orbital cellulitis and cerebral abscess. Difficulty of management in Indonesia during the COVID-19 pandemic includes hesitancy of the patient to seek medical care and the availability of surgical team for COVID-19-positive patients. Monitoring of corticosteroid and antibiotic use must be emphasized during the pandemic. Awareness of the disease needs to be increased in Indonesia.

Identification of a Unique Morphological Pattern for the Diagnosis of Fungal Rhinosinusitis

Fungal rhinosinusitis (FRS) is a relatively common, but often misdiagnosed disease of paranasal sinuses. The FRS is classified into invasive and non-invasive forms. The non-invasive form includes fungal ball and allergic FRS, and invasive form includes acute invasive FRS, chronic invasive FRS, and granulomatous FRS. Invasive fungal infections are associated with high morbidity and mortality, hence requiring urgent medical and surgical intervention. The histomorphology can help identify certain fungal organisms that cannot be cultured or are rarely visible in exudates. The morphologic diagnosis of tissue invasive and non-invasive fungal infection is essential for appropriate treatment. We analyzed cases of rhinosinusitis from 2017 to 2019 in Pathology Department at a tertiary care cancer hospital, Lahore, Pakistan. All clinical information was retrieved from patient records. Paraffin-embedded tissue blocks were stained with hematoxylin and eosin (H&E), special Grocott methenamine silver stain (GMS), and periodic acid Schiff stain (PAS) according to standard protocol. They were reviewed by two pathologists blinded by fungus status. A total of 169 cases of rhinosinusitis were reviewed. FRS comprised 146 (86.4%) of them. The mean age of patients with FRS was 32.8±14 years. The male:female ratio was 1.4:1. Maxillary sinus was the main site of involvement in 39 (27%) FRS cases. Aspergillus was identified in 117 (80.1%) cases of FRS. The culture reports were available in 44/146 (30.14%) FRS cases. They were negative in 22/44 (50.0%), and Aspergillus species were isolated in 18/44 (40.9%) cases of FRS. There were 84 (57.5%) cases of non-invasive FRS and 59 (40.4%) cases of invasive FRS. Among invasive FRS, there were 56 (38.4%) chronic granulomatous FRS cases including mixed patterns. Majority cases, 54 (96.4%), of chronic granulomatous FRS showed a unique crowded giant cell pattern comprising of foreign body and Langhans type giant cells. These giant cells were arranged closely forming irregular non-caseating granulomas surrounded by lymphocytes and fibrosis. Interestingly, the giant cells were scattered haphazardly without forming a granuloma as well. Fungal organisms were identified in all 56 cases of chronic granulomatous FRS. Histologically, predominant organism was Aspergillus in 48 (85.7%) on GMS and PAS stain. Our study observed a unique crowded giant cell pattern, which is a hallmark of invasive fungal infection. If pathologists are familiar with this unique pattern, they can make a quick and accurate diagnosis on histology. The physician can start antifungal treatment timely for better prognosis.

From delay to diagnosis: Chronic invasive fungal rhinosinusitis presenting with facial and orbital complications

Key Clinical Message

Early identification and management of chronic invasive fungal rhinosinusitis (CIFRS) is key to optimizing outcomes. A missed diagnosis can result in permanent vision loss, chronic facial pain, or death. We present a case of CIFRS and literature review.

Abstract

This case report presents a 56-year-old female with CIFRS involving orbital and facial complications. The patient experienced delayed diagnosis despite multiple ED visits for sinusitis with progressive facial pain and ocular deficits not alleviated with antibiotics, emphasizing the importance of early identification and maintaining high clinical suspicion for CIFRS. Prompt recognition, initiation of antifungal therapy, and aggressive surgical debridement were crucial for preventing disease progression and improving the patient's quality of life.

Infectious and Inflammatory Sinonasal Diseases

Rhinosinusitis is a commonly encountered disease. Imaging is not typically required in acute uncomplicated rhinosinusitis; however, it is integral in the evaluation of patients who present with prolonged or atypical symptoms or when acute intracranial complications or alternate diagnoses are suspected. Knowledge of the paranasal sinus anatomy is important to understand patterns of sinonasal opacification. Bacterial, viral, and fungal pathogens are responsible culprits and, with duration of symptoms, serve to categorize infectious sinonasal disease. Several systemic inflammatory and vasculitic processes have a predilection for the sinonasal region. Imaging, along with laboratory and histopathologic analysis, assist in arriving at these diagnoses.

Scedosporium apiospermum invasive rhinosinusitis in an elderly patient: diagnosis and treatment

Scedosporium apiospermum is a ubiquitous organism present in the environment and is rarely identified in rhinosinusitis. We report a case of invasive rhinosinusitis with Scedosporium apiospermum which made a definite diagnosis by metagenomic next-generation sequencing (mNGS) from a biopsy sample. The resection of the Scedosporium apiospermum pathological mass was performed with low-temperature plasma radiofrequency ablation. Six months of continuous oral voriconazole treatment was followed. The patient was asymptomatic with no signs of recurrence during the next 1-year follow-up.

"Chronic granulomatous invasive fungal rhinosinusitis associated with SARS-CoV-2 infection: A case report"

Introduction and importance

Granulomatous chronic invasive fungal rhinosinusitis (GCIFR) is a rare entity with scarce cases reported mainly in subtropical areas. Its prevalence among individuals with clinical suspicion of fungal rhinosinusitis has been reported in approximately 20% in subtropical populations, unlike North America with a prevalence of 0.5%. It is typically associated with Aspergillus flavus and the presence of noncaseating granulomas or Langerhans giant cells on histopathologic examination.

Case presentation

We describe a case of a patient with clinical history of recent SARS-CoV-2 infection and development of intense cephalalgia, visual impairment, palpebral ptosis, and limitation of extraocular movements. MRI demonstrated the presence of opacification of paranasal sinuses, and a left intraconal abscess. A surgical endoscopic approach was performed and histopathologic examination revealed frontal GCIFR and maxillary fungus ball. Treatment with IV azoles provided adequate clinical response.

Clinical discussion

The spectrum of the fungal rhinosinusitis disease is not clear. However, non-invasive fungal rhinosinusitis is not often found concomitantly with invasive types. GCIFR typically manifests with an indolent and gradual progression at early stages. Advanced stages can exhibit orbital and intracranial involvement leading to visual impairment, frequent relapses, and a poor prognosis. A higher incidence of invasive fungal rhinosinusitis has been reported in patients with SARS-CoV-2 infection despite an unremarkable medical history, associated with immune dysregulation.

Conclusion

GCIFR is a rare condition with few cases reported in America. Because of its uncommonness, its diagnosis is often delayed leading to increased morbidity and mortality.

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Granulomatous chronic invasive fungal rhinosinusitis is a rare entity with scarce cases reported.

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Non-invasive fungal rhinosinusitis is not often found concomitantly with invasive types.

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A higher incidence of invasive fungal rhinosinusitis is observed in SARS-CoV-2 infection.

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Early diagnosis of fungal rhinosinusitis is essential due to possibly fatal outcome.

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Physicians should be aware of atypical manifestations for a prompt diagnosis.

The Added Value of [18F]FDG PET/CT in the Management of Invasive Fungal Infections

Anatomy-based imaging methods are the usual imaging methods used in assessing invasive fungal infections (IFIs). [¹⁸F]FDG PET/CT has also been used in the evaluation of IFIs. We assessed the added value of [¹⁸F]FDG PET/CT when added to the most frequently used anatomy-based studies in the evaluation of IFIs. The study was conducted in two University Medical Centers in the Netherlands. Reports of [¹⁸F]FDG PET/CT and anatomy-based imaging performed within two weeks of the [¹⁸F]FDG PET/CT scan were retrieved, and the presence and sites of IFI lesions were documented for each procedure. We included 155 [¹⁸F]FDG PET/CT scans performed in 73 patients. A total of 216 anatomy-based studies including 80 chest X-rays, 89 computed tomography studies, 14 magnetic resonance imaging studies, and 33 ultrasound imaging studies were studied. The anatomy-based studies were concordant with the [¹⁸F]FDG PET/CT for 94.4% of the scans performed. [¹⁸F]FDG PET/CT detected IFI lesions outside of the areas imaged by the anatomy-based studies in 48.6% of the scans. In 74% of the patients, [¹⁸F]FDG PET/CT added value in the management of the IFIs.

Comparison Between Multiple and Solitary Fungus Balls: A Retrospective Analysis

OBJECTIVES

The most common type of noninvasive fungal rhinosinusitis is fungus ball (FB), which usually involves a solitary paranasal sinus. Multiple fungus balls (MFBs) are rarely reported in literature. The purpose of this study was to analyze and compare the clinical features of MFBs and solitary fungus ball (SFB).

METHODS

We retrospectively investigated consecutive cases of FB between 2001 and 2018 and compared the clinical records of SFB with MFBs with respect to demographics, clinical features, location, radiological findings, and operative outcome.

RESULTS

A total of 440 SFB and 43 MFBs cases were included in the study. The mean age was 55.3 ± 13.3 and 60.6 ± 10.9 years, respectively (P = .011). The incidence of MFBs obviously increased from 2001 to 2018. The clinical symptoms and laboratory examination were similar. On computed tomography images, complete opacification, septal deviation, Haller cells, and obstruction of ostiomeatal complex were more common (P < .05). The incidence of SFB on the left and right sides was similar, while MFBs were seen to involve both sides in 74.4%.

CONCLUSIONS

Compared with SFB, MFBs showed some special characteristics. The MFBs affected older patients showed wide range of lesions and complex anatomy. Surgical technique is very important. Much more attention should be paid to this not so uncommon disease during the perioperative period.