Allergic fungal sinusitis causing nasolacrimal duct obstruction

Nasolacrimal Duct Obstruction Secondary to Eosinophilic Chronic Rhinosinusitis: A Case Report

A 47-year-old Japanese woman presented with a 1-year history of right-sided epiphora. On initial consultation, the patient had a high right tear meniscus height. CT images revealed bilateral soft tissue opacification in the nasal cavity and maxillary, frontal, and ethmoid sinuses. The lesion in the right nasal cavity and maxillary sinus involved the right lacrimal sac and nasolacrimal duct. Blood test results showed elevated eosinophil count. Endoscopic sinus surgery and excisional biopsy of the nasolacrimal duct were performed. Histopathological examinations of the excised right nasolacrimal duct and nasal polyps from the nasal cavity and maxillary sinus showed high levels of eosinophilic inflammatory infiltrates. The definite diagnosis of eosinophilic chronic rhinosinusitis was made, based on clinical, radiological, and histopathological findings. At 1.5-year follow-up, tear meniscus height was normal, the lacrimal drainage system remained patent, and the rhinosinusitis did not recur.

Pediatric allergic fungal rhinosinusitis with extensive intracranial extension - Case report and literature review

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Allergic fungal sinusitis (AFRS) has become increasingly common. It’s defined as a noninvasive, benign inflammatory fungal disease of the sinuses which develops in young adults and adolescents.

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AFRS can present clinically in different ways. Its presentation can range from simple nasal obstruction to signs and symptoms of intra-orbital and/or intracranial complications.

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In pediatric cases being very aggressive, Careful clinical evaluation, detailed histopathological examination to rule out mixed types and malignancies.

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Lifelong follow up should be done to manage the recurrence.

Introduction

Over the last two decades, allergic fungal sinusitis (AFRS) has become increasingly common. It’s defined as a noninvasive, benign inflammatory fungal disease of the sinuses which develops in young adults and adolescents. Patients often complain of symptoms like nasal obstruction, congestion, purulent or clear rhinorrhea, anosmia, and headache. The cases are also presenting clinically with symptoms like epiphora and eye discharge as a result of nasolacrimal gland obstruction. In this article, we will review a unique case of AFRS, in an adolescent male. The case was diagnosed with intracranial extradural extension.

Case report

A 15 years old male with AFRS was diagnosed and managed. The case was diagnosed to have allergic fungal sinusitis based on Bent and Khun diagnostic criteria, presented with intracranial extradural extension.

Discussion

In our case, there were no irreversible complications except a recurrent polyp. The case was mainly complaining of long-standing nasal discharge and on-off headache with no orbital complaint and no other neurological signs. This shows a presentation of the fungal sinusitis and the need for aggressive intervention for AFRS both medically and surgically for pediatric patients as well.

Conclusion

To conclude, despite AFRS being categorized as a benign, non-invasive disease, its presentation can range from simple nasal obstruction to signs and symptoms of intraorbital and/or intracranial complications; with pediatric cases being very aggressive. Careful clinical evaluation, detailed histopathological examination, navigation assisted endoscopic sinus surgery followed by steroid treatment, and a lifelong follow up to manage the recurrence.

Two unusual cases of lacrimal sac inflammatory polyps with allergic mucin sine fungi

This case report deals with two patients with lacrimal sac swellings. Case 1 presented with bilateral sac swelling and Case 2 with a unilateral presentation. Dacrocystorhinostomy (DCR) followed by biopsies of both sacs in Case 1 revealed inflammatory polyps of the sac mucosa, identical in appearance to typical nasal allergic inflammatory polyps. The biopsies were accompanied by typical allergic mucin, featuring tiered mucin layers between which were numerous eosinophils, accompanied by Charcot-Leyden crystals. The histology of the dacryocystectomy specimen for Case 2 showed identical histopathological changes with the additional feature of prominent numbers of Immunoglobulin G (IgG)4-positive plasma cells in the stroma of the lacrimal sac inflammatory polyps. These features extend the sites affected by allergic inflammatory polyps and allergic mucin and possible pathogenesis is discussed.

Dacryocystitis As the Initial Presentation of Invasive Fungal Sinusitis in Immunocompromised Children

Sino-orbital fungal infection is a rare, but life-threatening disease seen mainly in immunocompromised patients. While initial clinical impression may vary, dacryocystitis has rarely been described as the initial presenting sign. The authors present 2 pediatric cases of dacryocystitis as the initial sign of invasive fungal sinusitis. To their knowledge, this presenting sign has not been previously reported in the pediatric population. Management strategies and outcomes are discussed.

Distinguishing the dominant species of pathogen in maxillary sinusitis by sequencing DNA dataset analysis

This study determined the microbial composition in maxillary sinusitis and determined the predominant fungal and bacterial species. Samples were obtained from 11 patients with fungal sinusitis and 2 healthy patients. The 13 samples were sequenced using an Illumina Hi-Seq 2000, and mapping to the human, bacterial, and the fungal genomes were based on several steps. Bioinformatics and statistical analyses were then performed for bacterial and fungal expressions in the samples. All samples were cultures for fungal growth. The sequencing data revealed that Aspergillus flavus and Aspergillus oryzae were the dominant fungal strains in the rhinosinusitis samples, and Bacillus cereus and Bacillus thuringiensis were the dominant bacterial strains. Indeed, the fungi and bacteria were associated with the development of fungal rhinosinusitis. Furthermore, B. cereus and B. thuringiensis may cooperate with Pseudomonas aeruginosa to inhibit the growth of fungal mycelia. Knowledge of the microbial composition can provide a diagnostic reference for patients with maxillary sinusitis.

Allergic fungal sinusitis involving the lacrimal sac: a case report and review

BACKGROUNd: We report a case of allergic fungal sinusitis (AFS) involving the lacrimal sac and review the current English literature. A literature search for AFS involving the lacrimal sac revealed two reports with only one of the two cases demonstrating histological evidence of fungal elements. This is just the third such case and only the second reported case with histopathologic confirmation of fungal elements by Gomori methenamine silver (GMS) stain.

MATERIALS AND METHODS

A PubMed database search was performed using combinations of the following key words: allergic fungal sinusitis, lacrimal sac, nasolacrimal duct, ophthalmology, epiphora, orbit. A 70-year-old white man with a history of chronic conjunctivitis and nasal polyps presenting with chronic epiphora was found to have dacryostenosis on the left side. A CT scan of the orbits revealed mucoperiosteal thickening completely obliterating the frontal, ethmoid and sphenoid sinuses.

RESULTS

A left external dacryocystorhinostomy (DCR) was performed and the lacrimal sac contents were studied histopathologically. Microscopic examination of the lacrimal sac contents disclosed allergic mucin with laminated aggregates of eosinophils in various stages of degeneration, Charcot-Leyden crystals and rare noninvasive fungal hyphae confirming the diagnosis of AFS. Fungal elements stained positively with Gomori methenamine silver stain.

CONCLUSION

Although rarely reported, AFS can affect the lacrimal sac. AFS should be suspected in patients with a history of recurrent refractory sinusitis, recurrent dacryocystitis and nasal polyposis. Early diagnosis is important for adequate treatment and prevention of recurrence.