Diagnosis Of Allergic Fungal Rhinosinusitis Research Articles

Allergic fungal rhinosinusitis presented as a unilateral nasal mass: A first case report from Thailand and literature review

Allergic fungal rhinosinusitis (AFRS) is a relatively new inflammatory sinonasal disease. Prevalence of the disease is reported to be highly different across Asia. A 23-year-old Thai male came to our hospital with left-sided nasal obstruction. Endoscopic examination found a mass originated from the left sphenoethmoidal recess. Incisional biopsy result of the mass indicated an inflammatory process and high level of serum specific IgE to several aeroallergens was found. Based on the biopsy results and other investigations, the diagnosis of AFRS was made and the patient was treated successfully with endoscopic sinus surgery and postoperative systemic/topical steroids. While AFRS is quite common in some regions, the disease is rarely encountered in Thailand and can be presented as a unilateral lesion, mimicking a tumor mass, which could lead to an incorrect diagnosis and inappropriate treatment. Even though AFRS is rarely reported in our country, it still can be found and might be recognized falsely as a neoplastic process. High level of awareness of the disease features could help to minimize inappropriate disease management.

The Evaluation of the Sensitivity and Specificity of a New Endoscopic Diagnostic Sign of Allergic Fungal Rhinosinusitis: Intrapolypoidal White Particles.

The diagnostic criteria of allergic fungal rhinosinusitis focus on characteristic clinical, radiographic, histopathologic findings and immunologic characteristics of the disease. None of these are useful for a prompt outpatient diagnosis of the condition. No clear endoscopic signs (pathognomonic) of polyps in allergic fungal rhinosinusitis are mentioned in the literature. The objective of this study is to describe and evaluate the sensitivity and specificity of an endoscopic sign the intrapolypoidal white particles for the diagnosis of allergic fungal rhinosinusitis in outpatient setting. In a descriptive, cross-sectional study, 46 chronic rhinosinusitis patients were examined by endoscope in the outpatient clinic. The endoscopic images of the nasal polypi were captured preoperatively. During endoscopic surgery, a sample of nasal polypi was taken for fungal staining and culture. Results of histopathology were compared to the impression of rhinologist on the images of nasal polypi captured preoperatively. The most common endoscopic features were the expansion of sinus (24, 52.2%) and intrapolypoidal white particles (50%). Intrapolypoidal white particles were calculated to have 85.71% sensitivity, 65.63% specificity, 52.17% positive predictive value, 91.3% negative predictive value and 71.74% diagnostic accuracy. This study offers a new endoscopic sign, intrapolypoidal white particles for diagnosing allergic fungal rhinosinusitis.

Allergic fungal rhinosinusitis: a clinical study in Srikakulam

<p class="abstract"><strong>Background:</strong> Allergic fungal rhinosinusitis is one of the differential diagnoses for chronic bacterial rhinosinusitis. Recognition and understanding of this unique disease will lead to efficient diagnosis and treatment of this curable process. India being a tropical country, provides an apt environment for fungal growth, the clinical diagnosis of Allergic fungal rhinosinusitis should not be missed and should be thoroughly investigated and managed to prevent recurrence. The objective of the study was to verify the management protocol for allergic fungal rhinosinusitis, after surgical clearance with functional endoscopic sinus surgery and postoperative histopathological examination and to see the efficacy of steroid and antifungal treatment</p><p class="abstract"><strong>Methods:</strong> A one year prospective study was considered with 28 patients from July 2016 to July 2017. Clinically suspected cases of rhinosinusitis depending upon their clinical presentation were subjected to nasal endoscopy, radiological examination and functional endoscopic sinus surgery. Postoperative histopathological examination was performed. Patients were followed up after giving steroid and antifungal treatment. </p><p class="abstract"><strong>Results:</strong> 28 cases were non-invasive. <em>Aspergillus</em> was found to be the most common isolate. The criteria responsible for good prognosis of allergic fungal rhinosinusitis management were mainly found to be functional endoscopic sinus surgery followed by topical corticosteroid therapy.</p><p class="abstract"><strong>Conclusions:</strong> Allergic fungal rhinosinusitis is a disease entity on the rise. Prompt diagnosis and intervention prevents recurrence and complications.</p>

Evaluation of Diagnostic Criteria for AFRS: A Hospital Based Study

Introduction
 Bent and Kuhn criteria are the most commonly accepted diagnostic criteria for diagnosis of Allergic Fungal Rhinosinusitis. Other diagnostic criteria for the diagnosis of Allergic Fungal Rhinosinusitis include unilateral nasal disease, Charcot Leyden crystals, bony erosions which form the minor criteria in the diagnosis of Allergic Fungal Rhinosinusitis. Clinical and Laboratory features in Allergic fungal rhinosinusitis are variable. These variations in the diagnostic criteria in the diagnosis of Allergic Fungal Rhinosinusitis have been analysed in the present study.
 Materials and Methods
 Prospective study was performed on group of 46 patients of Allergic fungal Rhinosinusitis presenting in the Otorhinolaryngology OPD with symptoms of Allergic fungal rhinosinusitis as diagnosed and persisting for more than 3 months during September 2009 to August 2010.
 Results
 Absolute eosinophil count was elevated in 80.43%, total serum IgE elevated in 69.67%, skin prick test was positive in 63.05% of patients. CT scan revealed that most common paranasal sinus involved is ethmoid sinus as seen in 73.91% cases., Sphenoid sinus was least involved as seen in 17.40% cases. More than one paranasal sinus were involved in 65.21% of the cases.,Complete opacification of all sinuses with calcified deposits were seen in 4.76% cases. Mucosal thickening was seen bilaterally in 73.91% of the patients and bony erosion was noted in 6.52% of patients. Histopathology of nasal smears revealed Eosinophilia in 80.43% of patients. Inflammatory Charcot Leyden crystals were found in 15.21% of the patients45.65% showed goblet cell hyperplasia . Other types of inflammatory cells were seen in 56.52%of the study population and 23.91% patients showed positive fungal hyphae.
 Discussion
 The significance of absolute eosinophil count, skin prick test, histopathology, CT Scan features and nasal smear cytology have been discussed along with review of literature.
 Conclusion
 Although management of Allergic Fungal Rhinosinusitis has advanced tremendously with better understanding of underlying pathogenesis, diagnostic strategies are still far from clear and are still emerging. Lot of research work has to be carried out regarding relevant diagnostic criteria for the disease.

Allergic Aspergillus Rhinosinusitis.

Allergic fungal rhinosinusitis (AFRS) is a unique variety of chronic polypoid rhinosinusitis usually in atopic individuals, characterized by presence of eosinophilic mucin and fungal hyphae in paranasal sinuses without invasion into surrounding mucosa. It has emerged as an important disease involving a large population across the world with geographic variation in incidence and epidemiology. The disease is surrounded by controversies regarding its definition and etiopathogenesis. A working group on “Fungal Sinusitis” under the International Society for Human and Animal Mycology (ISHAM) addressed some of those issues, but many questions remain unanswered. The descriptions of “eosinophilic fungal rhinosinusitis” (EFRS), “eosinophilic mucin rhinosinusitis” (EMRS) and mucosal invasion by hyphae in few patients have increased the problem to delineate the disease. Various hypotheses exist for etiopathogenesis of AFRS with considerable overlap, though recent extensive studies have made certain in depth understanding. The diagnosis of AFRS is a multi-disciplinary approach including the imaging, histopathology, mycology and immunological investigations. Though there is no uniform management protocol for AFRS, surgical clearing of the sinuses with steroid therapy are commonly practiced. The role of antifungal agents, leukotriene antagonists and immunomodulators is still questionable. The present review covers the controversies, recent advances in pathogenesis, diagnosis, and management of AFRS.

Immunohistochemical Dissimilarity between Allergic Fungal and Nonfungal Chronic Rhinosinusitis

Diagnosis of allergic fungal rhinosinusitis (AFRS) is complicated because of the presence of fungi on mucosal surfaces of sinonasal passages. The objectives of this study were to define, using immunohistochemistry, lymphocyte populations associated with noninvasive fungal-related chronic rhinosinusitis (CRS; AFRS and FBs [FB]) relative to CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP) as a means of diagnosing different forms of CRS. Sinus CT scans, nasal endoscopy scores, and the presence of eosinophilic fungal mucin or FBs were used to prospectively define patient groups with CRS who had failed medical treatment and were undergoing endoscopic sinus surgery. Four patient groups were identified: AFRS, FB, CRSwNP, and CRSsNP. Tissue specimens were studied and graded for histopathological changes. Immunophenotyping of mucosal lymphocytes was performed using anti-CD3, -CD20, -CD4, -CD8, -CD56, and -perforin antibodies. Nasal polyposis scores were similar between AFRS and CRSwNP. Radiological changes associated with AFRS can also be present in CRSwNP, e.g., heterogenicity in 9/30 (30%), expansion in 25/30 (83%), and bony attenuation of the ethmoid trabeculae in 19/30 (63%). Different grades of basement membrane thickness, edema, and fibrosis were observed. In both types of noninvasive fungal rhinosinusitis, CD3+ T lymphocytes were most commonly identified. In cases of AFRS, most T cells were CD8+ (p < 0.001). In FB cases, CD4+ lymphocytes were dominant (p < 0.001). In nonfungal CRS cases, CD20+ lymphocytes (B lymphocytes) predominated (p < 0.001). Although CT scans and histological examination can assist the diagnosis of rhinosinusitis, tissue immunophenotyping can be used in defining different types of fungal and nonfungal CRS cases.

Nasal Polyposis and Fungal Schizophyllum Commune Infection: A Case Report

We present a rare case of eosinophilic fungal rhinosinusitis with nasal polyps in a 32-year-old woman caused by basidiomycete fungus Schizophyllum commune. Diagnosis was done by the endoscopic nasal examination, computed tomography (CT) of the paranasal sinuses, the histopathological examination of polyps, the presence of eosinophils and fungal hyphae in nasal mucus and by the detection of S. commune by culture. The patient was successfully treated by combination of oral itraconazole and topical corticosteroid therapy combined with surgery. The pathogenesis and diagnosis of allergic fungal rhinosinusitis are also discussed.

Prevalence of fungal rhinosinusitis among patients with chronic rhinosinusitis from Iran

Summary Objective In the present study, we evaluated the occurrence of fungal rhinosinusitis (FRS) and those causative agents in patients with chronic rhinosinusitis (CRS) from Sari city, the capital of Mazandaran, a northern province of Iran. Patients and methods During one year, we studied FRS in 50 consecutive patients with CRS undergoing endoscopic sinus surgery at Boo Ali hospital from Sari city, Iran. Surgical sinus specimens were analyzed by histopathological and mycological methods. These samples were also processed for fungal culture. Total serum IgE was evaluated in all patients. Results Nasal obstruction and congestion was the commonest (96.0%) clinical presentation. Out of 50 patients, 70.0% and 40.0% patients were positive for fungi by microscopic and culture methods, respectively. Aspergillus (45.0%) was the commonest isolated fungi. Twelve (24.0%) patients showed allergic fungal rhinosinusitis (AFRS). Nasal polyps, history of atopy and eosinophilic mucin were seen in all patients with AFRS. Three (6.0%) patients met criteria for sinus fungal ball. Aspergillus was the most prevalent isolated fungi from all categories of FRS. Conclusion In concordant to other studies from warm and humid regions, we also showed that FRS is a common disorder in patients with CRS and Aspergillus as the prevalent isolated fungi in these patients. Sinonasal polyps, history of atopy and eosinophilic mucin showed strong association with AFRS, therefore, using of these items as important criteria in diagnosis of AFRS are emphasized.

Chronic fungal sinusitis in Tamilnadu, India

Objective The incidence of chronic fungal sinusitis in an immunocompetent population is on the increase in the past two decades. The present study was undertaken to assess the incidence and prevalence of the disease among the rural population in Tamilnadu. Materials and methods A prospective study of clinically diagnosed cases of chronic fungal sinusitis seen at the ENT department of SRM medical college hospital and research center, located in a village, was carried out during a period of 12 months from January to December 2007. Results Of the 20 cases investigated, 11 were males and nine females. The age range was from 16 to 68 years (average: 35 years).Their presenting symptoms included purulent nasal discharges and obstructions. Diagnosis of allergic fungal rhinosinusitis (AFRS) was established in nine cases by the characteristic computerized tomography (CT) scan findings, extraction of copious mucinous debris at surgery, presence of allergic mucin without invasion, detection of fungal hyphae, and Charcot-Leyden crystals in histological sections. Culture was done in five cases and Aspergillus species were isolated from four and Curvularia lunata from one. Chronic, nonspecific, inflammatory polyps were present in 11 cases. Functional endoscopic sinus surgery was successful in all. Conclusion AFRS is a relatively new disease. To our knowledge, only one previous report is available from Tamilnadu. Hence the present report for increasing the awareness of this clinical entity among clinicians.

Controversies surrounding the categorization of fungal sinusitis

Though rhinosinusitis is a common disorder, controversies surround the categorization of chronic rhinosinusitis (CRS) and the role of fungus in CRS. The diagnosis of each category is important for optimum therapy and predicting the course. Based on histopathological findings, fungal rhinosinusitis (FRS) can be broadly divided into two categories: the invasive and non-invasive depending on invasion of the mucosal layer. Three types of FRS are tissue-invasive: acute invasive, chronic invasive, & granulomatous. The two non-invasive FRS disorders are fungal ball, and fungus related eosinophilic rhinosinusitis including allergic fungal rhinosinusitis (AFRS). The distinction of granulomatous from chronic invasive type is not beyond controversy as both types have a chronic course and predominant orbital involvement. Maximum confusion surrounds the entity of fungus-related eosinophilic rhinosinusitis, and the definition of AFRS. In the diagnosis of AFRS, the detection of fungi in allergic mucin is considered important, although hyphae are sparse in sinus content. This leads to confusion in definition of this entity, especially with the description of two more closely related entities--eosinophilic fungal rhinosinusitis (EFRS) and eosinophilic mucin rhinosinusitis (EMRS). Recently reports of histologic invasion in possible cases of AFRS were also documented. Currently, there are more questions than answers concerning the categorization of FRS.

Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis

1) To investigate socioeconomic and demographic factors differentiating allergic fungal rhinosinusitis (AFRS) from other chronic rhinosinusitis (CRS) diagnostic groups. 2) To consider the potential impact of epidemiological differences on AFRS disease course. Retrospective review. Retrospective review of AFRS patients, CRS patients with nasal polyps (CRSwNP) without AFRS, and CRS patients without polyps (CRSsNP). Analysis of group differences was performed for age at presentation, gender, ethnicity, insurance status, and socioeconomic measures with the use of medical records and a South Carolina demographic database. AFRS presentation age was lower than CRSwNP and CRSsNP (P < 0.001). The AFRS group had more African Americans (P < 0.001) and uninsured or Medicaid patients (P < 0.001) than expected. AFRS patients resided in counties with higher poverty percentage (P = 0.011), lower median income (P = 0.048), and more African American residents (P = 0.020) than CRSsNP patients. No group differences existed for gender or physicians per 1000 county residents. Demographic and socioeconomic factors may affect AFRS presentation and treatment.

Allergic fungal rhinosinusitis: diagnosis and management

The proper diagnosis and treatment of allergic fungal rhinosinusitis remain controversial. We discuss recent additions to the literature regarding diagnosis and treatment of this condition. There is considerable overlap in the clinical features of allergic fungal rhinosinusitis and other forms of eosinophilic mucin chronic rhinosinusitis. Type 1 hypersensitivity and characteristic computed tomographic findings may have predictive value for a final diagnosis of allergic fungal rhinosinusitis, patients with which are more likely to have bony erosion than patients with other forms of chronic rhinosinusitis. The decreases in orbital volume associated with expansive allergic fungal rhinosinusitis disease may spontaneously improve after successful treatment. Most patients have detectable fungal-specific IgE in their so-called allergic mucin. Elevated levels of fungal-specific IgG3 are a consistent finding in patients with allergic fungal rhinosinusitis and eosinophilic mucin chronic rhinosinusitis. Antifungal treatment is still considered a treatment option, but further study is needed. Type 1 hypersensitivity to fungal antigens helps to distinguish allergic fungal rhinosinusitis from other forms of eosinophilic mucin chronic rhinosinusitis. Bony erosion and orbital expansion giving rise to proptosis are prominent features of allergic fungal rhinosinusitis. Advances in medical treatment will require prospective and controlled trials.

Fungal Cultures in Patients with Allergic Fungal Rhinosinusitis: Improving the Recovery of Potential Fungal Pathogens in the Canadian Laboratory

There is no uniform consensus on how to grow fungi from sinus aspirates in the Canadian setting. Protocols vary between institutions, and the positivity rate for fungal cultures ranges between 10 and 20% even when endoscopically obvious allergic mucin is being sent to the laboratory. The aim of this study was to compare the occurrence of positive fungal cultures obtained by our institution's fungal culture method with the occurrence obtained by the Mayo Clinic's fungal culture method. The ultimate aim was to propose a modified, feasible, standardized protocol for culturing fungi from sinus aspirates in the Canadian laboratory setting. Twenty-five allergic mucin aspirates were collected in 23 consecutive patients meeting the clinical diagnosis of allergic fungal rhinosinusitis. These samples were sent to the microbiology laboratory, where half of them were subject to our conventional laboratory protocol and the other half to the modified Mayo Clinic protocol. Positive fungal cultures were obtained in 16 of 25 (64%) specimens when the modified Mayo Clinic culture technique was used, with 12 cultures (48%) growing pathogenic fungus. Using our standard culture technique, 4 of 25 (16%) specimens resulted in a positive fungal culture, of which 3 grew pathogenic fungus (12%). A significantly greater fungal culture yield was obtained by the modified Mayo Clinic fungal culture technique than with our culturing technique. The modified Mayo Clinic fungal culture technique, although more costly, is a highly sensitive and effective technique for growing fungi from nasal specimens when compared with our traditional culture technique.

Value of investigation in the diagnosis of allergic fungal rhinosinusitis: results of a prospective study.

The authors report a prospective study in which the aim was to analyse the usefulness of different criteria in optimizing the diagnosis of allergic fungal rhinosinusitis. From 1995 to 1998, 165 patients were operated on for chronic rhinosinusitis. Investigations used in this study for the diagnosis of allergic Aspergillus rhinosinusitis consisted of an analysis of clinical, radiological, immuno-allergic criteria. Fourteen patients presented with allergic Aspergillus rhinosinusitis. One hundred and fifty-one patients did not present any of the necessary criteria for the diagnosis of allergic Aspergillus rhinosinusitis. The results show that the characteristic macroscopic appearance, the maxillary sinus localization, and the presence of positive specific IgE to Aspergillus fumigatus are arguments that reinforce the diagnostic certitude of allergic fungal sinusitis. No specific clinical or radiological criteria orients a diagnosis of chronic rhinosinusitis toward that of allergic fungal rhinosinusitis. The other immuno-allergic tests do not contribute to the diagnosis of allergic fungal rhinosinusitis. pathological, mycological, and