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

To do or not to do: Large-dose steroid treatment for severe vision loss secondary to compressive inflammatory optic neuropathy in the setting of invasive fungal sinusitis

Purpose

Invasive fungal sinusitis (IFS) is associated with high rates of morbidity and mortality and often presents with orbital apex syndrome. Prompt diagnosis and management are crucial to prevent irreversible visual loss. We report a case of an immunosuppressed patient with rapidly progressive severe visual loss associated with frontal lobe cerebritis and leptomeningitis related to IFS, causing an adjacent compressive inflammatory optic neuropathy, which was treated successfully by large-dose corticosteroids.

Observations

A 29-year-old woman with acute myeloid leukemia status post chemotherapy presented with right-sided headaches and periorbital swelling. Her examination was significant for subjective red desaturation and trace right eyelid edema and ptosis. The remainder of her initial ocular examination was normal. Her labs demonstrated neutropenia and thrombocytopenia. Imaging of the brain and orbits was concerning for extensive sinus disease with intracranial extension. An urgent multi-sinus and optic nerve decompression was performed given concern for compressive optic neuropathy, and the biopsy was consistent with invasive fungal infection. Despite aggressive antifungal treatment, vision in her right eye decreased rapidly to counting fingers. No optic nerve abnormalities were observed on serial MRIs, but adjacent inferior frontal lobe enhancement was present. After a vigorous debate in a multidisciplinary meeting, her severe vision loss was attributed to cerebritis causing an adjacent compressive inflammatory optic neuropathy, and large-dose intravenous (IV) steroid treatment was initiated while maintaining systemic antifungal therapy. Remarkably, she had a full recovery of her vision.

Conclusions and importance

Severe vision loss in IFS can occur due to compressive inflammatory optic neuropathy without direct fungal invasion as a contributing factor. Timely and effective intervention is crucial in preventing vision loss. Large-dose steroid therapy may be a potential treatment option for immunocompromised patients with invasive fungal sinusitis and intracranial invasion, provided strict fungal infection control measures are in place.

Invasive fungal rhinosinusitis: current evidence and research opportunities

PURPOSE OF REVIEW

To summarize the evidence surrounding diagnosis, treatment, prognosis, and surveillance of patients with acute invasive fungal sinusitis (AIFS) and discuss future research needs.

RECENT FINDINGS

New risk factors for AIFS such as COVID have been identified, and a new prognostic staging system has been developed.

SUMMARY

Most patients who develop AIFS are immunocompromised, with the majority having a history of diabetes or a hematologic malignancy. Unfortunately, there are not any highly sensitive and specific diagnostic tools. Therefore, a combination of signs and symptoms, imaging, endoscopy, biopsy, and labs should be used to diagnosis AIFS. Although surgery and systemic antifungals are known to improve outcomes, there is limited data on time to intervention, duration of antifungals, and surveillance patterns. There is also limited information on factors that can predict outcomes in AIFS patients. However, sensory/perceptual changes, prolonged neutropenia duration, and comorbidity burden may be associated with a poor prognosis.

Prognostic Factors for Survival Using a Clinical Severity Staging System Among Patients With Acute Invasive Fungal Sinusitis

Importance

Despite the aggressive progression of fulminant acute invasive fungal sinusitis (AIFS), data on prognostic factors have been disparate, hindering the development of a staging system. A composite staging system may improve prognostication for patient counseling and conduct of clinical research.

Objective

To identify prognostically important factors in AIFS and to incorporate the factors into a comprehensive Functional Severity Staging System and Clinical Severity Staging System.

Design, Setting, and Participants

This retrospective cohort study included adult patients diagnosed with pathology-proven AIFS from June 1, 1992, to December 31, 2022, at Washington University Medical Center and Barnes-Jewish Hospital, a tertiary care center in St Louis, Missouri. Data were analyzed from April to July 2023.

Main Outcome and Measures

Sequential sequestration and conjunctive consolidation was used to develop a composite staging system to predict 6-month overall survival.

Results

Of 71 patients with pathology-proven AIFS over the 30-year period, the median (range) age of the cohort was 56 (19-63) years, and there were 47 (66%) male patients. The median (range) follow-up time was 2 (0-251) months. There were 28 patients alive within 6 months, for a 39% survival rate. Symptoms, comorbidity burden, and presence and duration of severe neutropenia were associated with 6-month survival and were consolidated into a 3-category Clinical Severity Staging System with 6-month survival of 75% for stage A (n = 16), 41% for stage B (n = 27), and 18% for stage C (n = 28). The discriminative power of the composite staging system was moderate (C statistic, 0.63).

Conclusion and Relevance

This cohort study supports the clinical importance of symptomatology, comorbidity burden, and prolonged severe neutropenia at the time of AIFS presentation. The composite clinical staging system may be useful for clinicians when counseling patients with AIFS and conducting clinical research.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations

BACKGROUND

Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated.

RESULTS

A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains.

CONCLUSION

Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

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.

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.

Identifying Independent Predictors of Mortality in COVID-19 Patients with Mucormycosis

Background: Coronavirus disease 2019 (COVID-19) may lead to immunosuppression, leaving patients vulnerable to secondary invasive fungal infection like mucormycosis. The present study aimed to determine whether there are any risk factors associated with mortality in mucormycosis among COVID-19 patients. Patients and Methods: Patients with COVID-19 diagnosed with mucormycosis who received treatment at University Hospitals were included in the study. Complete blood count (CBC), glycated hemoglobin (HBA1c), C-reactive protein (CRP), serum albumin level, creatinine, ferritin levels, lactate dehydrogenase (LDH), D-dimer and histopathological observations were performed for all participants’ specimens. Results: The number (N) of patients included in the study was 46. About 85 % (39/46) of patients had post-COVID-19 syndrome and the other 7 cases were in the active phase of the disease. CRP, serum ferritin, D-dimer, CRP/albumin ratio and CRP/absolute lymphocyte counts were statistically significant (P<0.05) within non-survivors as compared to survivors. After analysis of multivariate analysis that patients had oxygen support, while elevated CRP/albumin ratios were independent predictors of mortality in COVID-19 patients associated with mucormycosis. Conclusions: Mucormycosis can be caused by immunosuppression conditions associated with COVID-19 infection. Oxygen levels and C-reactive protein/albumin are independent predictors of mortality and morbidity in post COVID-19 patients.

Allergic Fungal Sinusitis: Ophthalmic Complications Due to the COVID-19 Pandemic and the Potential of Telemedicine

We report a case of a 26-year-old female who initially presented to an outside optometrist with complaints of proptosis and decreased visual acuity. Magnetic resonance imaging (MRI) obtained at that time was concerning for allergic fungal sinusitis. Unfortunately, the patient’s referral to ophthalmology was delayed due to the coronavirus disease 2019 (COVID-19) pandemic. On presentation to ophthalmology one year later, the patient had clinically deteriorated with significant visual and olfactory loss. She underwent emergent endoscopic sinus surgery by otolaryngology with histological analysis of the sinus debris confirming allergic fungal sinusitis. This is a unique case demonstrating the devastating impact that the COVID-19 pandemic had on patient care for an otherwise treatable condition. We propose the utilization of telemedicine networks as a way to prevent similar complications.

Surgical debridement for acute invasive fungal rhinosinusitis during the pre-engraftment phase of allogeneic hematopoietic stem cell transplantation: Two case reports

RATIONALE

Surgical intervention may be not a contraindication for acute invasive fungal rhinosinusitis (AIFR) during the pre-engraftment period of allogeneic hematopoietic stem cell transplantation (allo-HSCT).

PATIENT CONCERNS

We present 2 cases involving patients with AIFR in the pre-engraftment phase of allo-HSCT.

DIAGNOSES

Both patients received surgical debridement combined with systemic antifungal treatment. The biopsies identified the diagnosis of AIFR in these 2 cases.

OUTCOMES

The 2 patients obtained normal hematopoiesis without recurrence of AIFR.

LESSON

Our experience with these 2 cases suggests that prompt endoscopic surgical debridement is not an absolute contraindication for allo-HSCT recipients with AIFR during the pre-engraftment period. If permitted, urgent, radical, and aggressive but careful endoscopic debridement should be performed together with systemic antifungal treatment once AIFR has been diagnosed or suspected.

Orbital Exenteration in Rhino-Orbito-Cerebral Mucormycosis: A Prospective Analytical Study with Scoring System

Mucormycosis is an uncommon, rapidly progressive, angio-invasive, commonly fatal, opportunistic fungal infection. The most critical decision in the management of rhinoorbital mucormycosis is whether the orbit should be exenterated. (1) To layout the indications of orbital exenteration in patients with rhino-orbito-cerebral mucormycosis. (2) To devise a scoring system that predicts the stage at which the exenteration needs to be carried out. A scoring system was devised by a team of experienced Otorhinolaryngologists and Ophthalmologists from prior experience in managing mucormycosis. All patients of mucormycosis visiting our hospital were admitted and included in the study. A total of 15 patients were included. The scoring system is based on 3 main criteria, namely: (1) clinical signs and symptoms. (2) Direct and Indirect Ophthalmoscopy. (3) Imaging. The Sion Hospital Scoring System is an accurate and promising measure to solve the dilemma that is associated with orbital exenteration in orbito-rhino-cerebral mucormycosis.

Slowly progressive invasive rhino-orbito-cerebral aspergillosis: case report and literature review

This is a report of a patient with aspergillosis infection, which was thought to be a tumoral lesion during its investigation. This is not a common disease in Western countries, and this report should increase our awareness for differential diagnosis of nasal masses. Early diagnosis is desired in order to increase the survival rates.

Acute invasive fungal rhinosinusitis: Survival analysis and the prognostic indicators

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is a highly mortal, progressive fungal infection of the paranasal sinuses and surrounding structures that is almost always seen in patients who are immunocompromised. Despite the use of newer antifungal treatments and early diagnosis, the prognosis of AIFR does not improve significantly. Due to the higher incidence of patients who are immunocompromised and have more complex disease, AIFR is a growing medical issue in tertiary medical centers.

OBJECTIVE

The aim of this study was to present the outcomes and analyze the prognostic indicators of patients with AIFR who underwent surgery.

METHODS

Between October 2009 and November 2014, 37 patients who underwent surgery for AIFR at a tertiary care university hospital were included in the study. Overall survival and disease-specific mortality and survival rates were calculated to estimate survival function. The impact of age, sex, underlying disease, extent of AIFR, applied medical treatment, and causative species (mucormycosis, aspergillosis) were also taken into consideration. Also, the effect of a variety of laboratory parameters, such as hemoglobin, leukocyte, neutrophil, lymphocyte, platelet, and C-reactive protein (CRP) levels, to survival were evaluated.

RESULTS

The median follow-up time was 58 days (interquartile range = 304). Overall and disease-specific mortality rates were 64.9 and 51.4%, respectively. Fever was the most common symptom (86.5%), along with nasal obstruction and/or fullness (48.6%) and epistaxis (48.6%). Age and sex did not have a significant impact on survival (p > 0.05). Palate involvement was significantly associated with mortality (p < 0.05). According to the results of Cox, regression analysis for disease-specific mortality rate, leukocyte and neutrophil counts as well as CRP levels had a significant effect on survival function (p < 0.05).

CONCLUSIONS

Palatal involvement was associated with a higher mortality in our study. Also, leukocyte counts, neutrophile counts, and CRP values had a significant impact on survival function. The reversal of the underlying disease and immunosuppression is as important as the medical and surgical treatment.

Invasive Aspergillus Sinusitis in Human Immunodeficiency Virus Infection: Case Report and Review of the Literature

Invasive Aspergillus (IA) sinusitis is a life-threatening opportunistic infection in immunocompromised individuals, but it is uncommon in human immunodeficiency virus (HIV) infection. To gain a better understanding of the characteristics of IA sinusitis in this population, we present a unique case of chronic IA sinusitis in an HIV-infected patient taking antiretroviral therapy and review the literature summarizing published cases of invasive aspergillosis of the paranasal (n = 41) and mastoid (n = 17) sinuses in HIV-infected individuals. Among these cases, only 4 were reported after 1999, and 98% of patients had acquired immune deficiency syndrome. Orbital invasion occurred in 54% of paranasal sinus cases, whereas intracranial invasion was reported in 53% of mastoid sinus cases. The overall mortality was 79%. We also discuss various clinical and immunologic factors that may play a role in the development of IA and consider the changing epidemiology of aspergillosis in the era of effective antiretroviral therapy.

Invasive fungal rhinosinusitis in adult patients: Our experience in diagnosis and management

BACKGROUND

This paper describes our experience in the management of acute and chronic invasive fungal rhinosinusitis (IFRS) in adults.

METHODS

Medical files of all patients aged >18 years treated in our institutions for IFRS from 2002 to 2013 were retrospectively reviewed.

RESULTS

A total of 18 cases (10 acute and 8 chronic) were recorded. In acute form, haematological malignancies represented the principal comorbidity (100%), while in chronic form this was diabetes mellitus (87.5%). All patients received systemic antifungal agents. Endoscopic sinus surgery was performed in 16/18 patients (88.9%). Among patients with an acute IFRS, 4/10 died of fungal infection (40%), on the other side 2/8 patients with chronic IFRS died of the evolution of the mycosis (25%).

CONCLUSIONS

Acute and chronic IFRS are different entities: in acute form, prognosis is poor, so therapy should be promptly performed, although host immune status and evolution of the haematological disease are key factors for the outcome. In chronic form, a wide surgical excision of the disease is recommended in order to obtain a complete removal of fungal infection. In both forms, early clinical findings are non-specific and ambiguous, so diagnosis depends on a high index of suspicion, taking into account predisposing factors.