NO FUN IN FUNGI: A CASE OF ALLERGIC FUNGAL RHINOSINUSITIS

Abstract

Introduction Allergic fungal rhinosinusitis (AFRS) is a noninvasive fungal disease of the sinuses arising from local fungal hypersensitivity and is a subtype of chronic rhinosinusitis (CRS). Typical signs and symptoms of AFRS may be similar to allergic rhinitis, CRS with/without nasal polyposis, or an acute bacterial exacerbation of CRS which can delay proper diagnosis and management. Case Description A 46-year-old immunocompetent Caucasian male from Florida with a history of allergic rhinitis and CRS presented with nasal congestion, anosmia, yellow-green nasal discharge, and post-nasal drip for 1 year despite daily use of intranasal fluticasone. Symptoms persisted despite the addition of intranasal azelastine, nasal saline irrigation, and a 14-day course of oral amoxicillin-clavulanate. Labs revealed an eosinophil count of 450 cells/mm3, total IgE of 127 KU/L, and specific IgE to dust mites, grasses, weeds, and molds (Alternaria, Aspergillus, Cladosporium, Curvularia). Rhinoscopy revealed bilateral, thick, mucopurulent discharge from the middle meatus and a left middle turbinate polyp. Oral clindamycin with a prednisone taper also did not improve his symptoms. CT sinus revealed complete opacification of the right maxillary sinus and left ethmoid air cells containing hyperdense material. He was referred to otolaryngology. Endoscopic sinus surgery revealed multiple nasal polyps, mucin with eosinophils, Charcot-Leyden crystals, and noninvasive fungal elements confirming AFRS. Oral prednisone and intranasal fluticasone were given post-operatively to reduce allergic inflammation and prevent disease recurrence. Discussion This case illustrates the importance of considering AFRS in patients with difficult to treat CRS with nasal polyposis, particularly those with IgE-mediated hypersensitivity to fungi. Allergic fungal rhinosinusitis (AFRS) is a noninvasive fungal disease of the sinuses arising from local fungal hypersensitivity and is a subtype of chronic rhinosinusitis (CRS). Typical signs and symptoms of AFRS may be similar to allergic rhinitis, CRS with/without nasal polyposis, or an acute bacterial exacerbation of CRS which can delay proper diagnosis and management. A 46-year-old immunocompetent Caucasian male from Florida with a history of allergic rhinitis and CRS presented with nasal congestion, anosmia, yellow-green nasal discharge, and post-nasal drip for 1 year despite daily use of intranasal fluticasone. Symptoms persisted despite the addition of intranasal azelastine, nasal saline irrigation, and a 14-day course of oral amoxicillin-clavulanate. Labs revealed an eosinophil count of 450 cells/mm3, total IgE of 127 KU/L, and specific IgE to dust mites, grasses, weeds, and molds (Alternaria, Aspergillus, Cladosporium, Curvularia). Rhinoscopy revealed bilateral, thick, mucopurulent discharge from the middle meatus and a left middle turbinate polyp. Oral clindamycin with a prednisone taper also did not improve his symptoms. CT sinus revealed complete opacification of the right maxillary sinus and left ethmoid air cells containing hyperdense material. He was referred to otolaryngology. Endoscopic sinus surgery revealed multiple nasal polyps, mucin with eosinophils, Charcot-Leyden crystals, and noninvasive fungal elements confirming AFRS. Oral prednisone and intranasal fluticasone were given post-operatively to reduce allergic inflammation and prevent disease recurrence. This case illustrates the importance of considering AFRS in patients with difficult to treat CRS with nasal polyposis, particularly those with IgE-mediated hypersensitivity to fungi.