Acute Fulminant Invasive Fungal Sinusitis Research Articles

Loss of contrast enhancement of the inferior rectus muscle on magnetic resonance imaging in acute fulminant invasive fungal sinusitis

Importance: This report describes a new magnetic resonance finding in acute fulminant invasive fungal sinusitis that may aid in the diagnosis of orbital involvement. Observations: The charts of two patients who presented with diabetic ketoacidosis and suspected acute fulminant invasive fungal sinusitis were retrospectively examined. Medical and surgical records, imaging studies, and histopathology specimens were reviewed. The two patients, a 58-year old female and 54-year-old male each had a contrast-enhanced magnetic resonance of the paranasal sinuses and orbits. Acute fulminant invasive fungal sinusitis with suspected orbital involvement was associated with focal loss of contrast enhancement of the inferior rectus muscle and adjacent orbital tissues. Fungal involvement of the inferior rectus muscle was confirmed on pathologic evaluation in both patients after exenteration. Conclusions and relevance: The finding of loss of contrast enhancement of an extraocular muscle on magnetic resonance may increase diagnostic confidence of orbital involvement in the setting of acute fulminant invasive fungal sinusitis and help guide surgical planning.

Unusual coexistence of sinonasal myeloid sarcoma and acute fulminant invasive fungal sinusitis: a diagnostic dilemma

We report a rare case of concurrent myeloid sarcoma and acute fulminant invasive fungal sinusitis in a patient with relapsed acute myeloid leukaemia. A 73-year-old man was diagnosed with acute myeloid leukaemia and developed relapse one year later. After two courses of azacytidine, he began suffering from a dull pain in the left temporal and orbital regions. Sinus computed tomography showed a localised lesion in the left ethmoid sinus, which rapidly progressed to an extensive intracranial mass within one month. Surgical debridement was performed, and histopathological analysis revealed the coexistence of myeloid sarcoma and acute fulminant invasive fungal sinusitis. The patient responded well to prompt surgical debridement, antifungal medication and radiotherapy. Coexistence of sinonasal myeloid sarcoma and acute fulminant invasive fungal sinusitis poses an urgent diagnostic and management challenge to clinicians. Timely recognition of this rare comorbid condition is warranted as application of appropriate treatment can save lives.

Loss of Contrast Enhancement of the Inferior Rectus Muscle on Magnetic Resonance Imaging in Acute Fulminant Invasive Fungal Sinusitis

Loss of Contrast Enhancement of the Inferior Rectus Muscle on Magnetic Resonance Imaging in Acute Fulminant Invasive Fungal Sinusitis

Fungal rhinosinusitis and imaging modalities

This report provides an overview of fungal rhinosinusitis with a particular focus on acute fulminant invasive fungal sinusitis (AFIFS). Imaging modalities and findings that aid in diagnosis and surgical planning are reviewed with a pathophysiologic focus. In addition, the differential diagnosis based on imaging suggestive of AFIFS is considered.

Computed Tomography and Magnetic Resonance Imaging Characteristics of Acute Invasive Fungal Sinusitis

To determine radiographic findings on computed tomography (CT) and magnetic resonance imaging (MRI) predictive of acute fulminant invasive fungal sinusitis (AFIFS) in an immunocompromised patient population. Retrospective case-control study. Tertiary referral hospital. Cases were 17 immunocompromised patients with confirmed AFIFS after surgical debridement or biopsy. Controls were 6 immunocompromised patients histopathologically negative for AFIFS after surgical debridement or biopsy. Computed tomographic and MRI scans were independently reviewed by 2 neuroradiologists to identify imaging characteristics predictive of AFIFS. Operative reports and histopathologic, microbiologic, and survival data were reviewed. No significant differences with regard to baseline characteristics between the 2 groups were identified. There was moderate or substantial agreement (κ=0.40-0.77) between the 2 radiologists for all imaging parameters except MRI loss of contrast enhancement (κ=0.16). Magnetic resonance imaging was more sensitive than CT for the diagnosis of AFIFS (sensitivity 85% and 86% for both reviewers compared with 57% and 69%). Extrasinus invasion with MRI was the most sensitive individual parameter (87% and 100%). Magnetic resonance imaging and CT had similar specificities, and perisinus invasion was the most specific individual parameter (83% and 83% for MRI compared with 81% and 83% for CT). The positive predictive values were high for both imaging modalities (93% and 94% for MRI compared with 89% and 93% for CT). The negative predictive values were lower for both modalities and varied more between reviewers (71% and 100% for MRI compared with 45% and 67% for CT). Magnetic resonance imaging is more sensitive for detecting early changes of AFIFS than CT. Both imaging modalities have similar specificities. Perisinus invasion with MRI was the most sensitive and specific single parameter evaluated.

Temporal Lobe Abscess in a Patient With Isolated Fungal Sphenoiditis

Pathology References Isolated sphenoid sinusitis accounts for 2-3% of all sinus infections evaluated by radiologic imaging. Fungal sphenoiditis is present in approximately 5% of isolated sphenoiditis. The most common presenting symptom is frontal/retro-orbital headache; this occurs in roughly 70% of cases. Nasal obstruction is the next most common symptom presenting in 30% of cases. Noninvasive fungal sphenoid sinusitis rarely presents with serious complications. However, diplopia and/or transient vision loss have been the most severe reported complications and have been seen in up to 3% of cases. Intracranial extension and cerebral abscess is another serious complication of fungal sphenoiditis, and to our knowledge has not been reported until now. Intracranial extension from sinusitis is a rare but potentially fatal disease characterized by bony erosion of the skull base and fungal extension into the adjacent cavities, such as the orbit or cranial vault. It is usually associated with acute fulminant invasive fungal sinusitis (AFIFS) in the immunocompromised population, such as patients who have undergone hematopoietic stem cell transplantation or solid organ transplant, those with HIV/AIDS or diabetes mellitus, or those who are undergoing treatment with chemotherapy or immunosuppressants.3, 4 However, this complication has now been shown to very rarely occur in immunocompetent individuals as well, and seems to be increasing in frequency in this population.4-7 Of the approximately twenty pathogenic fungi, the three most common fungal infections in the nasal sinuses are the opportunistic genera of Aspergillus, Mucor, and Candida, of which Aspergillus is the most prevalent organism.1, 8 While rare, each of these can invade the adjacent structures, with Mucor being the most invasive and requiring the most aggressive surgical treatments. Intracranial extension and abscess formation most commonly occurs from the frontal sinus to the frontal and frontoparietal areas of the brain. 4 The rarest occurrence of invasive fungal sinusitis is seen in the sphenoid sinus, due to only 2.7% of all sinus infections occurring there.9 The rarity of this infection in comparison to other sinuses is because of both the anatomical orientation of the sphenoid sinus receiving little directed airflow, and because the sinus mucosa is lined by relatively few glands, producing less mucus to serve as a reservoir for infection.10 When invasion does occur from the sphenoid sinus, it can occur through one of two mechanisms: retrograde thrombophlebitis through diploic veins of the skull, or by direct extension through normal anatomic pathways or wall erosion.11 The fungus can either enter the frontoparietal areas of the brain similar to extension from the frontal and ethmoid sinuses, or it can extend into the cavernous sinus, causing visual defects secondary to destruction of cranial nerves III, IV, V, and VI. Another potential site of invasion is the temporal lobe, which has rarely been documented.10, 11 Case Report

An early detection protocol for invasive fungal sinusitis in neutropenic patients successfully reduces extent of disease at presentation and long term morbidity

To evaluate a multidisciplinary early intervention protocol for invasive fungal sinusitis (IFS) in neutropenic patients and its effect on degree of tissue involvement at time of presentation and effect on morbidity and mortality. Retrospective review. A chart review was performed for cases of acute fulminant IFS in neutropenic patients at Emory University Hospital from 1995 to 2007. Inclusion required tissue diagnosis of IFS, neutropenia, and adequate records of the following: tissue involvement at presentation, number and extent of surgical procedures performed, morbidity, and mortality. Group 1 included patients prior to 2001, and group 2 included patients after protocol initiation in 2001. The groups were compared for the number of tissue sites involved at presentation, number of surgical procedures performed, long-term morbidity, and mortality. Twenty-eight cases of IFS were identified. The average number of sites involved at presentation was 2.5 in group 1 and 1.5 in group 2 (P = .059). The average number of procedures was 2.2 in group 1 and 1.0 in group 2 (P = .026). Long-term morbidity occurred in 43% (6/14) of group 1 patients compared with 7.1% (1/14) of group 2 patients (P = .029). Mortality from IFS was 7.1% in group 1 and 7.1% in group 2. IFS requires early diagnosis and treatment for optimum outcome. A protocol of early intervention for neutropenic patients is effective in early detection of IFS with fewer sites of involvement at diagnosis, fewer surgeries, and less long-term morbidity. No difference in survival was found, as this is more a factor of the underlying cause of the neutropenia.

Orbital and Cranial Nerve Presentations and Sequelae are Hallmarks of Invasive Fungal Sinusitis caused by Mucor in Contrast to Aspergillus

Acute fulminant invasive fungal sinusitis (IFS) is a rapidly progressing, destructive process almost exclusively affecting immunocompromised patients. Outcome differences have been found in patients with Mucor and Aspergillus. We performed this study to compare the presenting symptoms and long-term morbidity with IFS caused by Mucor versus Aspergillus species. Retrospective chart review was performed of 48 patients with 49 cases of acute fulminant IFS over a 19-year period. Presenting symptoms and long-term morbidity related to the orbits and cranial nerves were evaluated. Mucor was found in 22 cases and Aspergillus was found in 27 cases. Orbital (proptosis, periorbital edema, and ophthalmoplegia) and cranial nerve symptoms were seen at presentation more often in Mucor (6 [27%] and 9 [41%]) than in Aspergillus patients (3 [11%] and 7 [26%]; p=0.079). Long-term orbital and cranial nerve sequelae occurred in 16 (72%) Mucor cases and 10 (37%) Aspergillus cases (p=0.0210). The IFS-related mortality was 32% (7) in the Mucor group and 11% (3) in the Aspergillus group (p=0.089). Patients with acute fulminant IFS present with similar sinus symptoms; however, there is a trend toward a greater prevalence of orbital and neurological symptoms in patients with Mucor versus Aspergillus. Long-term orbital and neurological morbidity is more prevalent in patients with Mucor compared with Aspergillus. These data suggest that the presence of orbital and neurological symptoms at presentation warrants more aggressive surgical intervention because of the likelihood of Mucor.

Chronic invasive fungal rhinosinusitis

Chronic invasive fungal rhinosinusitis is an increasingly recognized, but inadequately characterized, disease entity which is separate and distinct from acute fulminant invasive fungal sinusitis and allergic fungal sinusitis. Chronic invasive fungal rhinosinusitis is divided into granulomatous and nongranulomatous subtypes based on histopathology, but the clinical distinction between the two subtypes is not clear. Current management includes varying degrees of surgical débridement and a prolonged course of antifungal agents. A protracted clinical course with recurrence after treatment is common.