Invasive Fungal Sinusitis Research Articles

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.

Rhinoscleroma: Mimicking As Acute Invasive Fungal Pan-Sinusitis

Rhinoscleroma is a chronic indolent granulomatous infection of the nose and the upper respiratory tract. The average time of presentation between the onset and diagnosis is about a decade. An unusual case of Rhinoscleroma in a young immunecompetent male with a two month history mimicking as invasive fungal sinusitis is being presented. While Radiological appearance is not pathognomonic of rhinoscleroma, nasal endoscopy is both diagnostic and therapeutic. Histopathology report is confirmatory for rhinoscleroma.

Primary B cell lymphoma of paranasal sinuses: a diagnostic surprise.

Primary lymphomas of paranasal cavities are rather uncommon entities. They have a variable presentation from fulminant destructive manifestations to chronic indolent type of disease. Chronic indolent form may mimic invasive fungal sinusitis in its presentation. Unless high index of suspicion is held and appropriate histopathology sections are taken from specimen, its diagnosis can be deceitful. We here by report a case of primary lymphoma of the paranasal sinuses which was radiologically and clinically suspected to be a invasive fungal sinusitis and later was proven to be a B cell lymphoma. Clinical similarities between lymphoma and invasive fungal sinusitis along with management issues are discussed in this article.

S283 – Invasive Fugal Sinusitis: Pathognomic Presentation in MRI

Objectives The aim of this study was to evaluate the pathognomic findings of magnetic resonance image(MRI) and determine the benefit of MRI in early diagnosis of invasive fungal sinusitis(IFS). Methods We retrospectively reviewed 15 cases of biopsy-proven IFS. The preoperative MRI was reviewed to identify the pathognomic findings and correlation between radio-graphic and surgical findings were investigated. Results The MRI findings included decreased signal intensity on T1-weighted images with no enhancement on contrast-enhanced images and markedly decreased signal intensity on T2-weighted images in all cases. In our series, the interval between the onset of symptom and timing of MRI was from 48 hours to 2 weeks. Radiographic findings were correlated with histopathologic findings in 13 of 15 patients. Conclusions We could find typical MRI findings in IFS. MRI should be considered early in patients at high risk for IFS.

Current Indications for Pediatric Endoscopic Sinus Surgery

Objective To describe current indications, sinonasal pathologies, and outcomes of endoscopic sinus surgeries (ESS) in children. Methods Retrospective chart review of children that underwent ESS at a children's tertiary care facility from July 2004 to June 2007 was performed. Demographic data, clinical profiles, surgical procedures including revisions, and complications were analyzed. Results 117 ESS were performed on 88 children (mean age 9.6 years) and 4 adults; 64 were male. The most common indications for ESS in descending order were: chronic rhino-sinusitis (CRS) (n=29), subperiosteal periorbital abscess (n= 20), sinonasal neoplasm (n= 11), intracranial complication from acute sinusitis (n=8), CRS with cystic fibrosis (n=8), complicated acute sinusitis (n=6), allergic fungal sinusitis (n=5), antrochonal polyps (n=2), invasive fungal sinusitis (n=1), and other pathologies (n=2). 21 children underwent an average of 2.2 sinus procedures. Majority of revisions were on patients with tumors (46%), allergic fungal sinusitis (40%), intracranial complication from acute sinusitis (38%), complicated acute sinusitis (33%), subperiosteal periorbital abscess (15%), CRS with cystic fibrosis (13%), and CRS (10%). Two children had excessive bleeding requiring another anesthetic to complete the procedure; 1 patient had airway obstruction from a tracheal blood clot requiring bronchoscopy. Conclusions More than 2/3rds of patients had ESS for indications other than uncomplicated CRS. Approximately 1/4 required revision surgeries reflecting the complexity of sinonasal pathologies seen in children compared with adults. Otolaryngologists performing pediatric ESS must not only be skilled in sound surgical technique, but must have appropriate interdisciplinary professional support to address the associated clinical problems seen in children.

Syndromes of invasive fungal sinusitis

Invasive fungal sinusitis should be suspected in immunocompromised or diabetic patients who present with acute sinusitis, inflammation of nasal septal mucosa, unexplained fever or cough, or the orbital apex syndrome. Histopathological studies are required to differentiate among these syndromes. Acute (fulminant) invasive fungal sinusitis has been called mucormycosis, zygomycosis and fulminant invasive sinusitis. Fever, cough, crusting of nasal mucosa, epistaxis, and headache are the most common presenting symptoms. Histopathological studies show hyphal invasion of blood vessels, vasculitis with thrombosis, and tissue infarction. Reports of granulomatous invasive fungal sinusitis come primarily from Sudan, but also from India, Pakistan, and the United States. Patients usually present with proptosis, appear to be immunocompetent and are infected almost exclusively with A. flavus. Chronic invasive fungal sinusitis can be distinguished from the two other forms of invasive fungal sinusitis by its chronic course, dense accumulation of hyphae resembling a mycetoma, and association with the orbital apex syndrome, diabetes mellitus, and corticosteroid treatment. Biopsy and orbital exploration show vascular invasion by fungal elements and only a sparse chronic inflammatory infiltrate.

Traditional open surgery for advanced benign nasal tumours in an era of endoscopy: review of 38 cases.

During the past decade open nasal surgery has been overtaken by endoscopic resection in the management of benign sinonasal tumours in the advanced countries. However, due to limited availability of endoscopic surgical facilities and training in most parts of sub-Saharan Africa, open surgery still seems popular. This report determines the indications and outcome of open nasal surgery for benign tumours in a resource – poor tertiary centre in sub-Saharan Africa and compares with endoscopic resection. This is retrospective study of 38 open surgeries done by the authors for cases of benign sinonasal tumours. Seventeen (45%) caldwel-luc procedures, 12 (31%) external (lynch-howarth) fronto-ethmoidectomy and 9(24%) lateral rhinotomy were carried out. The indications were simple nasal polyps 17(45%), mucocoele 10(26%), inverted paplloma 8(21%), invasive fungal sinusitis 2(5%) and ossifying fibroma 1(2%). Postoperatively, recurrence was 1/17(6%) caldwel-Luc surgery and 1/9 (11%) lateral rhinotomy for inverted papilloma. Facial scar was seen in 21/38(55%) but the cosmetic effect of the scars was acceptable to our patients. Postoperative stay was between 5 to 17 days. We conclude that open nasal surgery met the therapeutic expectations of our patients. The recurrence rate compared with that of endoscopic resection reported in the literature and cosmetic effect of facial scar was acceptable to the patients, however, postoperative stay in the hospital is longer. It is our hope that this will serve as a baseline to compare the result of endoscopic nasal surgery in future when it becomes a widespread procedure in the developing countries. African Journal of Health Sciences Vol. 14 (1-2) 2007: pp. 44-48

Significance of MUC5B antibody in differential diagnosis between Aspergillus species and Mucorales of fungal sinusitis

To differentiate between Aspergillus species and Mucorales of fungal sinusitis by immunohistochemistry. Formalin-fixed paraffin-embedded tissue blocks of 66 cases of fungal sinusitis were retrieved from the archival files of Department of Pathology of Beijing Tongren Hospital during the period from 2001 to 2006. The samples included 29 cases of fungal balls, 12 cases of allergic fungal sinusitis, 24 cases of chronic invasive fungal sinusitis and 1 case of acute invasive fungal sinusitis. The types of fungi were 44 Aspergillus species (31 cases of A. fumigatus, 7 cases of A. flavus and 6 cases of A. terreus) and 22 Mucorales (14 cases of Mucor species and 8 cases of Rhizopus species). Immunohistochemistry was performed with MUC2, MUC5AC and MUC5B antibodies. The results were compared with histochemical study for periodic acid-Schiff (PAS) and Grocott methenamine silver (GMS) stains. Immunohistochemical study for MUC5B showed that the positive rate of Aspergillus species was 90.9%, in contrast to 4.5% in Mucorales (P < 0.001). The expression of MUC2 and MUC5AC was completely negative, whereas PAS and GMS stains were positive in all cases. MUC5B antibody appears to be a useful immunohistochemical marker for identifying fungal types in tissue sections, especially in distinguishing between Aspergillus species and Mucorales in fungal sinusitis.

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.

Mycological profile of fungal sinusitis: An audit of specimens over a 7-year period in a tertiary care hospital in Tamil Nadu

Fungi are being increasingly implicated in the etiopathology of rhinosinusitis. Fungal sinusitis is frequently seen in diabetic or immunocompromised patients, although it has also been reported in immunocompetent individuals. Invasive fungal sinusitis, unless diagnosed early and treated aggressively, has a high mortality rate. Our aim was to look at the mycological and clinical aspects of fungal sinusitis in a tertiary referral center in Tamil Nadu. This is a retrospective audit conducted on fungal culture positive sinus samples submitted to the Microbiology department from January 2000 to August 2007. Relevant clinical and histopathological details were analysed. A total of 211 culture-positive fungal sinusitis samples were analysed. Of these, 63% had allergic fungal sinusitis and 34% had invasive fungal sinusitis. Aspergillus flavus was the most common causative agent of allergic fungal sinusitis and Rhizopus arrhizus was the most common causative agent of acute invasive sinusitis. A significant proportion of these patients did not have any known predisposing factors. In our study, the etiology of fungal sinusitis was different than that of western countries. Allergic fungal sinusitis was the most common type of fungal sinusitis in our community. Aspergillus sp was the most common causative agent in both allergic and chronic invasive forms of the disease.

Fungal Internal Carotid Artery Aneurysms: Successful Embolization of an Aspergillus-Associated Case and Review

Fungal aneurysms of the carotid artery are rare. We report here a case of Aspergillus fumigatus invasive sphenoidal sinusitis complicated by carotid artery aneurysms in a severely neutropenic patient who was successfully treated with a combination of antifungal therapy and embolization of all aneurysms. Carotid aneurysms were suspected when severe epistaxis occurred during follow-up for sinusitis. MRI angiograph and cerebral angiograph revealed 5 aneurysms involving the right intracavernous carotid artery. Coil endovascular embolization was successfully used for the first time in this context, and the patient is alive 2 years later. We also reviewed the literature and identified 10 cases of fungal carotid artery aneurysms. Aspergillus species was the most common fungal organism. All patients were immunocompromised and had to be treated surgically. Internal carotid arterial involvement is a rare but life-threatening complication of invasive fungal sinusitis. Fungal aneurysms should be diagnosed early, so that the embolization procedure can be performed before the occurrence of severe bleeding.

Imaging Features of Invasive and Noninvasive Fungal Sinusitis: A Review

Fungal sinusitis was once considered a rare disorder but is now reported with increasing frequency throughout the world. The classification of fungal sinusitis has evolved in the past two decades, and this entity is now thought to comprise five subtypes. Acute invasive fungal sinusitis, chronic invasive fungal sinusitis, and chronic granulomatous invasive fungal sinusitis make up the invasive group, whereas noninvasive fungal sinusitis is composed of allergic fungal sinusitis and fungus ball (fungal mycetoma). These five subtypes are distinct entities with different clinical and radiologic features. The treatment strategies for the subtypes are also different, as are their prognoses. An understanding of the different types of fungal sinusitis and knowledge of their particular radiologic features allow the radiologist to play a crucial role in alerting the clinician to use appropriate diagnostic techniques for confirmation. Prompt diagnosis and initiation of appropriate therapy are essential to avoid a protracted or fatal outcome.

Pituitary apoplexy due to mucormycosis infection in a patient with an ACTH producing pulmonary tumor

Rhinocerebral mucormycosis is an acute, fulminating form of invasive fungal sinusitis occurring principally in individuals who are immunologically or metabolically compromised. The incidence of pituitary apoplexy ranges from 6% to 17%, presenting as a capsule rupture in up to 1.7–2.0%. Isolated cases of mucormycosis are associated with solid tumors and Cushing’s syndrome. A 42-year-old, diabetic woman, with Cushing’s syndrome of 5 years duration presented with hemiplexy, hemiparesis and altered speech following a syncopal episode and fall. Brain CT scan showed a left temporal lobe infarction. The patient deteriorated rapidly and she died 4 days later. Autopsy findings included: plurihormonal pituitary adenoma with extension to the sphenoid bone and sellar erosion; many thick, septated, mucormycosis hyphae; and recent fronto-temporal brain infarction. Also, a solitary adrenal corticotropic hormone (ACTH)-producing neuroendocrine tumor, 3 cm in diameter, was found in the left lung. This patient illustrates the correlation between ACTH-producing ectopic pulmonary tumor, pituitary apoplexy and mucormycosis.

Invasive fungal sinusitis: An effective combined treatment in five haematological patients

Invasive fungal rhinosinusitis (IFR) is a life-threatening infection. Its onset is subtle and a late diagnosis leads to severe complications. Death may occur within a few weeks notwithstanding treatment. We describe a comprehensive pre- and post-operative approach to care for haematological patients with IFR. Five haematological patients with IFR were treated with systemic antifungal therapy and endoscopic surgical debridement of infected tissues, followed by amphotericin-B directly instilled in the sinuses by a new type of ethmoidal drainage. The IFR remitted in all cases; after 32 months of follow-up, three patients are still alive, and two have died of other causes. Two of the patients who experienced IFR progression to the brain at the IFR onset are still alive. The pharmacological and surgical approach with the post-operative local therapy by a new ethmoidal drainage system could support radical antifungal sinus treatment, thus improving the overall survival.

Medical management of invasive fungal sinusitis

The incidence of fungal infection continues to rise as the population of immunocompromised individuals increases. Despite the enlarging numbers of infections, there are only a few antifungal agents for treatment of deep seated invasive infections. This article focuses on general concepts of antifungal therapies and provides a detailed review of each antifungal agent available for treatment of deep seated mycoses of nose and paranasal sinuses.

Mucormycosis Mimicks Sinusitis in a Diabetic Adult

Fungal sinusitis caused by invasive fungal infections, such as Mucormycosis, occurs predominantly in an immunocompromised patient. However, invasive cranial bone mycoses are rare and are usually associated with host immunodeficiency. They are difficult to diagnose, and in many cases are fatal. Treatment consists of antifungal chemotherapy, radical surgical debridement, and control of the underlying immunological condition. We report a case of Mucormycosis in a patient with type 1 diabetes mellitus. The patient had a history of dental pathology and associated renal dysfunction. The patient was managed by extensive surgical debridement followed by amphotericin B lipid complex injection (Abelcet 5 mg/bw kg/day) as an antifungal agent. Our patient's ocular function was affected. The radical treatment and follow-up by a multidisciplinary team eliminated the mucor-related consequences, however, the patient died because of end-stage renal failure. In conclusion, type 1 diabetes may be associated with invasive fungal sinusitis.

Invasive Fungal Sinusitis Caused by Pseudallescheria Boydii: Case Report and Literature Review

Fungal sinusitis secondary to Pseudallescheria boydii is rare, as only 25 cases have been previously reported in the literature. Although Pboydii resembles Aspergillus on pathologic examination, it is typically resistant to amphotericin B. Therefore, culture is necessary to differentiate the two. Patients with P boydii sinusitis should generally be treated with a combination of surgery and antifungal therapy. Combination treatment is particularly important for immunocompromised patients with fungal invasion because mortality among these patients is high. The prognosis is better for immunocompetent patients, even those with fungal invasion. We describe a new case of invasive fungal sinusitis secondary to P. boydii infection, and we review the literature on this emerging pathogen.

Resolution of invasive fungal sinusitis in two pediatric patients with acute lymphoblastic leukemia

Resolution of invasive fungal sinusitis in two pediatric patients with acute lymphoblastic leukemia

08:18 AM: Frozen-Section Biopsy Analysis for Invasive Fungal Sinusitis

08:18 AM: Frozen-Section Biopsy Analysis for Invasive Fungal Sinusitis

Primary aspergillosis of the sphenoid sinus with pituitary invasion – a rare differential diagnosis of sellar lesions

Aspergillosis belongs to the group of mycotic diseases of paranasal sinuses. The invasive forms, and particularly the fulminant forms, are potentially fatal. Isolated aspergillosis of the sphenoid sinus or the clivus is a difficult diagnosis, since the often misleading clinical manifestations of this rare disease develop late. These patients become apparent by neurological signs such as cavernous sinus syndrome, pseudotumor of the pituitary or the orbit. Diagnosis is often made intra-operatively or on histological examination. We report a case of invasive aspergillosis uniquely involving the sellar area revealed by clinical features suggesting a pseudotumor of the pituitary. Although such lesions are almost always seen in immune suppressed subjects, in our case, the patient was immune competent and had no past history of sinusitis.The question of whether, and when to perform limited or extensive surgery remains an issue for discussion, owing to the rarity of this disease honed by lack of experience. It depends on several factors: the kind of disease, the immunity, the subtype of invasive fungal sinusitis and the degree of tissue invasion.