Immunohistochemical dissimilarity between allergic fungal and nonfungal chronic rhinosinusitis

Dupilumab: An emerging therapy in allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is a highly resistant disease and is challenging to treat. Patients with recurrent attacks of the disease despite surgical management can benefit from biologics as adjunct therapies. Dupilumab has shown promising endpoints in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). This case series reports 4 patients with resistant AFRS concomitant with asthma, for which dupilumab therapy was administered. Long-term follow-ups showed that dupilumab improved the symptoms and improved the results of objective tools such as imaging and pulmonary function test.

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.

Quality-of-life outcomes after sinus surgery in allergic fungal rhinosinusitis versus nonfungal chronic rhinosinusitis

BACKGROUND

Given the differences in pathophysiology between allergic fungal rhinosinusitis (AFRS) and other chronic rhinosinusitis (CRS) subgroups, it remains unclear about whether these patients respond differently to a combination of surgical and medical treatments.

OBJECTIVE

To evaluate differences in quality-of-life (QoL) outcomes for a cohort of patients who underwent endoscopic sinus surgery (ESS) for CRS.

METHODS

This retrospective review included patients with CRS who underwent ESS between 2010 and 2013. QoL was measured by using the 22-item Sino-Nasal Outcome Test (SNOT-22). Variables collected included baseline demographics, SNOT-22 scores before ESS and at 1, 3, 6, 9, and 12 months after ESS. Groups tested were CRS with nasal polyposis, CRS without nasal polyposis (CRSsNP), and patients with AFRS. A linear mixed- effects regression model was used to calculate the adjusted mean QoL differences.

RESULTS

Among the 250 patients included, 61.6% had CRS with nasal polyposis (n = 154), 28.8% had CRSsNP (n = 72), and 9.6% had AFRS (n = 24). Significant differences were seen in SNOT-22 scores between pre- and postoperative visits and between the etiologic subgroups (p < 0.001). Multivariate analysis revealed significantly greater improvement in QoL for patients with AFRS in comparison with those with CRSsNP at the 9-month follow-up (change in SNOT-22 score, 22.6 [95% confidence interval, 1.2-44.1]; p < 0.0) and the 12-month follow-up (change in SNOT-22 score, 20.2 [95% confidence interval, 0.5-39.9]; p < 0.04).

CONCLUSIONS

Patients with AFRS experienced a more-prolonged QoL benefit from surgical and targeted medical intervention compared with those with CRSsNP, which may reflect the severity of inflammation that they presented with compared with other CRS subtypes.

Amphotericin B nasal irrigation as an adjuvant therapy after functional endoscopic sinus surgery

BACKGROUND

Fungus-driven inflammation is proposed to play an important role in the pathogenesis of chronic rhinosinusitis (CRS). Previous studies evaluated the efficacy of intranasal amphotericin B (AMB) in the treatment of patients with CRS, but the results were controversial. The purpose of this study was to evaluate the efficacy of 100 μg/mL of AMB nasal irrigation as postoperative care after functional endoscopic sinus surgery (FESS).

METHODS

Patients with CRS who received FESS for treatment were recruited and randomly assigned to two groups at 1 month after surgery. Patients in the AMB group received 100 μg/mL of AMB nasal irrigation daily for 2 months, and those in the normal saline (NS) group received NS solution nasal irrigation daily for 2 months. Pre-FESS, pre-irrigation, and postirrigation sinonasal symptoms were assessed by questionnaires, and the patients received endoscopic examination, acoustic rhinometry, smell test, and saccharine transit test.

RESULTS

Seventy-seven patients were enrolled between June 2012 and December 2014. Among the patients who completed the study, 38 received AMB irrigation, and 39 received NS solution irrigation. Although all the patients reported improvement after irrigation, there was no difference in outcome between patients who received AMB and those who received NS solution.

CONCLUSION

Our study showed that nasal irrigation with 100 μg/mL of AMB did not confer a greater benefit than that of NS solution nasal irrigation in post-FESS care.

Development of Aspergillus protease with ovalbumin-induced allergic chronic rhinosinusitis model in the mouse

BACKGROUND

Chronic rhinosinusitis (CRS) is a multifactorial inflammatory disease. Particularly, eosinophilic CRS is often recalcitrant to treatment, so an appropriate animal model is required to evaluate the pathogenesis of, and to develop therapies for, recalcitrant eosinophilic CRS. This study aimed to improve the ovalbumin (OVA)-induced mouse model of eosinophilic/allergic CRS by combining OVA with Aspergillus protease, which is known to trigger allergic reactions in mouse lungs.

METHODS

In a model of allergic CRS, mice were challenged intranasally with Aspergillus protease combined with OVA. Local and systemic responses were measured. Protease (0.54 U) from Aspergillus oryzae, prepared with or without OVA (75 micrograms), OVA alone, or saline, was administered intranasally to wild-type mice for 5 weeks. Sinonasal complex samples were evaluated histologically, and interleukin (IL)-4, IL-5, IL-6, macrophage inflammatory protein (MIP) 2, and tumor necrosis factor (TNF) alpha were measured in nasal lavage fluid. A differential white blood cell count was also performed.

RESULTS

OVA alone induced minimal eosinophilic inflammation in sinonasal mucosa, while protease + OVA and protease alone induced moderate eosinophilic inflammation. Protease + OVA elevated eosinophil counts in blood comparable with controls, but not compared with OVA alone. Although IL-4, IL-5, IL-6, MIP-2, and TNF-alpha were increased in all study mice, the levels of IL-4 and IL-6 were higher in mice treated with protease + OVA than in mice treated with OVA alone. Protease alone excessively elevated the levels of IL-6, MIP-2, and TNF-alpha, not Th2 cytokines, compared with OVA alone and protease + OVA.

CONCLUSION

Aspergillus protease combined with OVA induced more severe allergic inflammation in sinonasal mucosa compared with OVA alone and similar eosinophilia. This model could be more relevant to recalcitrant eosinophilic CRS in humans than OVA-induced allergic CRS.

CD8(+) T cells implicated in the pathogenesis of allergic fungal rhinosinusitis

Fungi in paranasal sinuses are characteristic and considered a major pathogenic factor in a subset of chronic rhinosinusitis (CRS) patients, known as allergic fungal rhinosinusitis (AFRS). CD8⁺ T cells are enriched in AFRS sinuses but their role in fungal-specific responses is unknown. Alternaria alternata– and Aspergillus fumigatus–specific T lymphocyte responses were investigated in 6 AFRS patients, 10 eosinophilic mucus CRS (EMCRS) patients, 10 CRS with nasal polyps (CRSwNPs) patients, 6 allergic rhinitis with fungal allergy (ARFA) patients, and five controls. Fungal-specific proliferation of human peripheral blood mononuclear cells (PBMCs) was studied prospectively. Proliferating cells were examined for CD3, CD4, CD8, and CD25 expression. Relevant clinical characteristics, fungal allergy, detection of fungi in sinuses, and CD4⁺ and CD8⁺ composition of sinus T cells were also examined. CD4⁺ T-cell division to fungi occurred in all samples, regardless of fungal allergy or CRS. Fungal-specific CD8⁺ T-cell division occurred in all ARFA and control samples and the majority of CRSwNP patients; however, CD8⁺ T cells failed to proliferate in AFRS and EMCRS patients. The CD8⁺ T cells from AFRS patients also did not up-regulate the activation marker, CD25, with fungal antigen exposure. Presence of A. alternata– and A. fumigatus–specific CD4⁺ and CD8⁺ T-cell proliferation in healthy individuals, ARFA, and CRSwNP patients suggests that both T-cell subsets may be important in immune responses to these fungi. In AFRS and EMCRS patients, only fungal-specific CD4⁺ T-cell proliferation occurred; hence, a lack of CD8⁺ T-cell proliferation and activation in the presence of sinus eosinophilic mucus in these patients, regardless of fungal allergy, is a novel finding. This raises the question whether a dysfunctional CD8⁺ T-cell response predisposes to ineffective clearance and accumulation of fungi in the sinuses of susceptible patients.

Novel treatment of allergic fungal sinusitis using omalizumab

A case report of recalcitrant allergic fungal sinusitis (AFS) refractory to systemic corticosteroids and multiple functional endoscopic sinus surgeries (FESSs) treated with anti-IgE antibody omalizumab is reported. AFS is often classified with chronic rhinosinusitis (CRS). Although similar symptoms are among the two diseases, AFS has a unique pathophysiology. Patients with AFS demonstrate type 1 hypersensitivity to fungal allergens, increased total serum IgE, increased CD8⁺ T-cell prevalence, and IL-4 and IL-5 response. Omalizumab should be considered in the treatment of AFS.

Impact of fungal load on diagnosis and outcome of allergic fungal rhinosinusitis

Fungal load colonization may modify the classic eosinophilic inflammation in allergic fungal rhinosinusitis (AFRS). We aimed to evaluate the impact of fungal load on diagnosis and outcome of AFRS. In the present cohort study fungal load differences were determined prospectively according to Gomori methenamine silver (GMS) fungal stained (histopathological and cytological examination) with the tenacious mucus, cheesy clay-like materials and sinus mucosa/polyps in 12 AFRS patients. Two groups with different fungal loads, AFRS with (six patients) and without (six patients) high fungal loads (HFL) were evaluated for nasal endoscopic score, paranasal sinuses CT score, histopathological and immunohistochemical changes. Endoscopic outcome scoring differences were evaluated for 1 year after endoscopic sinus surgery and 1 month oral corticosteroids treatment. No differences were observed between both groups (AFRS with/without HFL) concerning the total CT score and opacification features (P > 0.05). Eosinophils and CD3 + CD8 + T cell were dominant in both groups. More edema and less fibrosis were observed in HFL group. Gliotoxin producers Aspergilli were present in all HFL in comparison to 5/6 (83.3%) in cases without HFL. Fewer patients 1/6 (16.6%) and less number of recurrences/year 0.1 ± 0.4 occurred in the AFRS with HFL compared to the AFRS without HFL [5/6 (83.3%) and 1.16 ± 0.7) (P = 0.021 and 0.023, respectively]. In addition to mucus and mucosal tissues, cheesy clay-like materials must be assessed in AFRS cases. Although patients of AFRS with HFL had negligible clinical differences from ordinary AFRS without HFL, they had better outcome after treatment.