A rare case of allergic fungal rhinosinusitis in Indonesian elderly: A case report and diagnostic procedure

Background

Allergic fungal rhinosinusitis (AFRS) is a rare case.

Case presentation

A 63-year-old-man presented right nasal congestion one year ago. There was a polyp in the right nasal cavity supported CTScan showed a solid mass with central hyperattenuating of ±8.4 × 2.4 × 4.4 cm. Total IgE value was 1,227 IU/ml, while Aspergillus specific IgE and Mucorous specific IgE using the micro-Elisa technique were negative or less than 0.35 IU/ml. The skin prick test was positive on exposure to house dust, cotton, chicken meat, and cow's milk. Mucosal polypoid and allergic mucin were found during functional endoscopic sinus surgery (FESS). Histopathology showed inflammatory cells of eosinophils.

Discussion

These results lead to a diagnosis of AFRS according to the Bent and Kuhn criteria. The highest incidence rate is in adolescents and young adults but it occurs in the elderly. So, some of the signs and symptoms of AFRS in adolescents and young adults do not appear.

Conclusion

AFRS can only be diagnosed during FESS when mucins are found, this case appear in the elderly to be very interesting.

•Allergic Fungal Rhinosinusitis (AFRS) is a rare case in otorhinolaryngology.

•Diagnosis of AFRS can only be obtained during functional endoscopy sinus surgery (FESS).

•Hypersensitivity type 1, polyp nasi, typical CT Scan finding, and mucin during FESS were found.

Sinobronchial allergic mycosis syndrome in an elderly male

Background

Allergic bronchopulmonary aspergillosis (ABPA) and allergic fungal rhinosinusitis (AFRS) are characterized by hyper-responsiveness of the respiratory tract and the nasal cavity and paranasal sinuses, respectively to Aspergillus species and AFRS causes chronic rhinosinusitis. Herein, we report the first case of sinobronchial allergic mycosis (SAM) syndrome, defined as ABPA with concomitant AFRS, caused by Aspergillus fumigatus patient > 80 years.

Case presentation

An 82-year-old male with interstitial pneumonia who returned for follow-up exhibited high-attenuation mucus plug in the right intermediate bronchial trunk, infiltration in the right lung field, and right pleural effusion on regular chest computed tomography (CT). We found unilateral central bronchiectasis in the right upper lobe. Similarly, CT scan of the paranasal sinuses revealed high-attenuation mucus plugs in left ethmoid sinuses. Biopsy specimens from the plugs in the right intermediate bronchial trunk and the left ethmoid sinuses revealed allergic mucin with layers of mucus eosinophils, eosinophil-predominant mixed inflammatory cell infiltrate and Aspergillus hyphae. The patient fulfilled all the major criteria for ABPA and AFRS, and was diagnosed with SAM syndrome. CT scan of the lung and paranasal sinuses revealed apparent amelioration after oral steroid therapy.

Conclusion

Despite mostly reported in relatively young patients, SAM syndrome can occur in elderly individuals as well.

Are allergic fungal rhinosinusitis and allergic bronchopulmonary aspergillosis lifelong conditions?

Aspergillus fumigatus can cause several allergic disorders including Aspergillus-sensitized asthma, allergic bronchopulmonary aspergillosis (ABPA), and allergic fungal rhinosinusitis (AFRS). ABPA is an immunological pulmonary disorder caused by allergic reactions mounted against antigens of A. fumigatus colonizing the airways of patients with asthma (and cystic fibrosis). Allergic bronchopulmonary mycosis is an allergic fungal airway disease caused by thermotolerant fungi other than A. fumigatus On the other hand, AFRS is a type of chronic rhinosinusitis that is also a result of hypersensitivity reactions to the presence of fungi that become resident in the sinuses. The pathogenesis of ABPA and AFRS share several common features, and in fact, AFRS can be considered as the upper airway counterpart of ABPA. Despite sharing similar immunopathogenetic features, the simultaneous occurrence of the two disorders is uncommon. Due to the lacuna in understanding of the causative mechanisms, and deficiencies in the diagnosis and treatment, these disorders unfortunately are lifelong illnesses. This review provides an overview of the pathogenesis, diagnosis, and long-term outcomes of both these disorders.