Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis

Diagnosis and Management of Candida and Other Fungal Infections of the Head and Neck

Fungi are common inhabitants of the oral and nasal mucosa, and therefore the differentiation between colonization and pathogenicity in the setting of upper respiratory tract infection symptoms can be difficult. Fungal head and neck infections occur in both immunocompetent and immunocompromised persons, and patients with neutropenia, diabetes mellitus, corticosteroid use, and HIV infection are particularly susceptible to serious and potentially life-threatening infections. Invasive fungal head and neck infections generally require extensive surgical debridement and prolonged systemic antifungal therapy, and frequently carry a poor prognosis when the underlying immunosuppression cannot be corrected. In contrast, noninvasive fungal head and neck infections often respond to short courses of systemic or topical antifungal therapy, or require limited surgical debridement alone.

Allergic bronchopulmonary aspergillosis: a review of a disease with a worldwide distribution

Allergic bronchopulmonary aspergillosis (ABPA), an immunologically mediated lung disease, occurs predominantly in patients with asthma. This chronic relapsing disorder ranges clinically from mild asthma to fatal destructive lung disease and is caused by hypersensitivity to colonized Aspergillus fumigatus (Af). The immunopathogenesis of the disease is yet to be understood clearly. Specific IgE-Af and IgG-Af, the serological markers, contribute to the diagnosis. Radiologically, ABPA is characterized by fleeting pulmonary infiltrates often confused with pulmonary tuberculosis. However, central bronchiectasis on computed tomography is considered to be the hallmark of the disease. Early diagnosis and therapy with prednisolone, the cornerstone of management, could alter the course of the disease and prevent the development of end-stage lung fibrosis.

[Sino-nasal endoscopic surgery in fungal sinusitis. Our experience]

Fungal sinusitis is a rare entity which has increased amongst immunocompromised individuals. Records of thirteen patients treated of fungal sinus disease between 1995 and 2001 were reviewed. Histopathological studies demonstrated infection due to Aspergillus in eight patients and due to Mucormycosis in five patients. The surgical debridement via endoscopic sinus surgery was the essential part of the management. The follow-up is 12-72 months (mean 29.08). The main clinical findings and a review of the literature are presented. We conclude that endoscopic sinus surgery is the treatment of choice for fungal sinusitis except in advanced cases of mucormycosis in which a combined approach is still necessary together with intravenous antifungal drugs (amphotericin B).

Sinobronchial allergic mycosis: the SAM syndrome

We contend that the presence of concomitant allergic fungal sinusitis (AFS) and allergic bronchopulmonary mycosis in the same patient represents an expression of the same process of fungal hypersensitivity in the upper and lower airways. We have termed this process the SAM syndrome, an acronym for sinobronchial allergic mycosis. Diagnostic criteria have been established for the SAM syndrome, and the clinical characteristics of one previously unreported and four previously reported patients have been tabulated. Patients with the SAM syndrome have chronic sinusitis involving multiple sinuses, asthma, immediate cutaneous reactivity to fungal allergens, peripheral eosinophilia, and radiographic evidence of bronchiectasis. Total serum IgE levels are usually elevated as well. A variety of chest radiographic abnormalities may occur, ranging from mass lesions to diffuse pulmonary infiltrates and even normal findings on chest radiographs. Patients present for an evaluation of either sinus or lung disease and, at that time, demonstrate no clinical features that distinguish them from patients with isolated sinus or lung disease. All patients reported to date have had clinical responses to therapy with corticosteroids. We postulate that SAM is underdiagnosed in patients with AFS, a disease recently reported from medical centers in the southeastern and western United States. Moreover, since our patient had a mutation in the cystic fibrosis transmembrane conductor regulator (CFTR) gene, we further hypothesize that CFTR gene mutations may play an important role in the pathogenesis of the SAM syndrome.

Clinical presentation of allergic fungal sinusitis in children

OBJECTIVE

To compare the differences in the clinical and radiographic presentation of allergic fungal sinusitis in children and adults.

STUDY DESIGN

Retrospective chart and computed tomography review.

METHODS

The settings included a tertiary care children's hospital, adult academic private hospital, and academic affiliated county hospital. All patients with documented allergic fungal sinusitis who underwent computed tomography evaluation and had surgical treatment of their disease from 1988 to 1999 were included in the study. In total, 151 patients aged 5 to 75 years; 44 of these patients were less than or equal to 17 years of age (children) and 107 were greater than 17 years of age (adults). Main outcome measures included 1) the presence of obvious bony facial abnormalities on presentation, 2) bilateral or unilateral sinus disease on presentation, 3) the presence of asymmetrical disease on presentation, 4) the presence of bony extension on computed tomography scan, and 5) type of fungus present.

RESULTS

Fifteen of 36 (42%) pediatric patients and 10 of 103 (10%) adult patients had obvious alteration of their facial skeleton (proptosis, telecanthus, or malar flattening) on presentation (P <.05). Proptosis was the most common facial abnormality in both groups and was seen more often in children (8 of 36 [22%]) than in adults (9 of 103 [9%]) (P <.05). Twenty-eight of 40 (70%) pediatric patients and 37 of 100 (37%) adult patients presented with unilateral sinus disease (P <.05). Thirty-five of 40 (88%) pediatric patients and 58 of 100 (58%) adults presented with asymmetrical disease (P <.05). Computed tomography scans showed that 10 of 40 (25%) pediatric patients and 23 of 100 (23%) adult patients had bony erosion with extension of disease into surrounding structures (P >.05). Cultures from both adults and children showed mainly Bipolaris and Curvilaria species in equal amounts (P >.05). Adults had a greater incidence of Aspergillus species.

CONCLUSIONS

Presentation in pediatric patients with allergic fungal sinusitis is different from that in adults, with children having obvious abnormalities of their facial skeleton, unilateral sinus disease, and asymmetrical disease more often. Findings on computed tomography scan show an equal amount of bony erosion with extension of disease. The types of fungus cultured in the sinus cavities are similar in both groups.

Concomitant allergic bronchopulmonary aspergillosis and allergic Aspergillus sinusitis: a review of an uncommon association*

BACKGROUND

Although thought to have common immunopathological processes, concomitant occurrence of allergic bronchopulmonary aspergillosis (ABPA) and allergic Aspergillus sinusitis (AAS) appears to be rarely reported as to date only five detailed case reports are available.

OBJECTIVE

To present a review of seven cases of concomitant ABPA and AAS, three of whom were earlier reported for their unusual presentations.

METHODS

Patients with ABPA with nasal symptoms were evaluated radiologically. Consent was taken for antral wash and/or Caldwell-Luc operation in those with radiological evidence of sinusitis and the material was sent for histopathological and mycological studies.

RESULTS

Of the 95 patients with ABPA, 22 had radiological evidence of sinusitis. Nine consented to surgery, seven of whom were diagnosed as concomitant AAS. Nasal symptoms preceded chest symptoms in two patients, vice versa in one and occurred simultaneously in four. Familial occurrence of ABPA, middle lobe syndrome and collapse with effusion along with an operated aspergilloma were seen in one patient each. Transient pulmonary infiltrates and central bronchiectasis were seen in all patients. Computed tomography of the paranasal sinuses, carried out in six patients, revealed mucosal thickening with hyperdense lesions, without any bony erosion or destruction. All patients had positive skin tests, positive precipitin study and raised total and specific IgE. Allergic mucin was seen in all patients, fungal hyphae in five, and culture grew Aspergillus spp. in four. All patients responded favourably to oral prednisolone.

CONCLUSION

Concomitant occurrence of ABPA and AAS seems to be infrequently recognized. Since asthma and sinusitis are often seen by two different specialities, the occurrence of AAS in ABPA and ABPA in AAS may easily be overlooked.

A superantigen hypothesis for the pathogenesis of chronic hypertrophic rhinosinusitis, allergic fungal sinusitis, and related disorders

BACKGROUND

Chronic eosinophilic-lymphocytic respiratory mucosal inflammatory disorders include hypertrophic sinus disease, allergic fungal sinusitis, allergic bronchopulmonary aspergillosis, and chronic severe asthma. They have many analogous or shared aspects of pathology at molecular, cellular, and clinical levels of analysis.

OBJECTIVE

To propose a theory, and supporting data through comprehensive literature review, that unifies these diseases' pathogenesis. METHODS AND DATA SOURCES: Current medical literature was used as supportive background information. Reinterpretation of existing studies and reasoned speculation were used when necessary and identified where used. English language MEDLINE articles that referenced sinusitis, rhinosinusitis, allergic fungal sinusitis, asthma, allergic bronchopulmonary aspergillosis, nasal polyp, superantigen, and T cell receptor from 1983 to present were potentially used as background or supportive information. Additional referenced articles, published abstracts, and National Center for Biotechnology Information Entrez protein database searches were used. Case reports, studies, review articles, and textbooks were included.

RESULTS

Multiple lines of evidence support the proposed hypothesis that microbial T cell superantigen production, persistence, and host-responsiveness are the fundamental components that unify the pathogenesis of all common chronic eosinophilic-lymphocytic respiratory mucosal inflammatory disorders. Superantigen amplification of preexisting immunopathology is the proposed mechanism for disease induction and maintenance. Preexisting immunopathology is created in the individual by a potential heterogeneity of immunopathologic signals that can include type I immediate hypersensitivity, other antigen-specific immune responses, cytokine dysregulation, eicosanoid dysregulation, various genetic mutations, and other molecular pathology. Although the ability to develop chronic severe inflammatory disease is dependent upon this immunopathology, host T cell receptor V beta genetics and persistent superantigen production/exposure at the respiratory mucosa by relevant superantigen-producing extra- or intracellular microbes are postulated to be required. This mechanism for disease pathogenesis may also apply to other disorders. Approaches to prove this theory and its predictions are presented.

CONCLUSIONS

The pathogenesis of all the disorders discussed can be unified through the superantigen hypothesis proposed. Multiple lines of evidence support this hypothesis. How we view these common conditions will change, and new research into pathogenesis and treatment will occur if this proves true.

Fungal rhinosinusitis: diagnosis and therapy

Fungal rhinosinusitis presents in five clinicopathologic forms, each with distinct diagnostic criteria, treatment, and prognosis. The invasive forms are acute fulminant, chronic, and granulomatous ("indolent") invasive fungal sinusitis. The noninvasive forms are fungal ball ("sinus mycetoma") and allergic fungal sinusitis (AFS). AFS is the most common form of fungal rhinosinusitis. Patients with AFS are atopic to aeroallergens including the involved fungal organism, immunocompetent, have nasal polyps and chronic allergic rhinosinusitis, often produce nasal casts, and may occasionally present with proptosis from orbital extension of disease. Sinus CT shows sinus mucosal hypertrophy and often hyperattenuation of sinus contents. Diagnosis is made from surgical histopathology with or without an associated positive surgical sinus fungal culture. The histopathology shows extramucosal allergic mucin that stains positive for scattered fungal hyphae and eosinophilic-lymphocytic sinus mucosal inflammation. Bipolaris spicifera is the most common fungus cultured. The immunopathology of AFS has been shown to be analogous to allergic bronchopulmonary aspergillosis. Treatment requires surgery and aggressive postoperative medical management with close follow-up. Medical treatment includes allergy medications, allergen immunotherapy, and in many cases the addition of oral corticosteroids. Although medical management clearly improves patient outcomes, more studies are needed because AFS recurrence rates remain high.

Allergic fungal sinusitis: an immunohistologic analysis

BACKGROUND

Allergic fungal sinusitis is a noninvasive form of fungal sinusitis that has recently been delineated as a distinct clinicopathologic entity. It is increasingly recognized as a cause of chronic sinusitis, with the primary causative agents being members of the Dematiaceae fungus family. Although its immunopathogenesis has not been elucidated, the eosinophil is a prominent inflammatory cell on histologic examination.

OBJECTIVE

We sought to characterize the involvement of eosinophils in sinus tissue and accompanying mucin from patients with allergic fungal sinusitis. As a comparison, neutrophil and mast cell involvement was also evaluated in the same group of patients.

METHODS

Tissue specimens from 8 patients with allergic fungal sinusitis, along with 8 nasal polyp specimens from patients without allergic fungal sinusitis, were stained by using indirect immunofluorescence for eosinophil granule major basic protein (MBP). Neutrophil elastase and mast cell tryptase staining was also performed on the same allergic fungal sinusitis and nasal polyp tissues.

RESULTS

MBP was diffusely localized within the mucin, showing intense staining at the periphery and variable staining of degenerated cell clusters throughout. Extracellular MBP in the mucin was strikingly greater than intact eosinophil staining. Diffuse extracellular neutrophil elastase was also present in the mucin. Mucinous areas showed no tryptase localization. Adjacent nonmucinous areas of respiratory mucosa showed predominantly cellular staining with eosinophil MBP, neutrophil elastase, and mast cell tryptase. MBP staining of nasal polyps showed a predominantly cellular pattern with focal areas of extracellular deposition.

CONCLUSIONS

Given the known toxicities of eosinophil granule MBP and neutrophil elastase, their extracellular presence supports the contribution of these proteins in the pathogenesis of allergic fungal sinusitis and further indicates that eosinophil and neutrophil activation occurs in the disease.

Medical treatment of allergic fungal sinusitis

LEARNING OBJECTIVES

This review of allergic fungal sinusitis (AFS) will enable the reader to (1) differentiate AFS from the other forms of fungal sinusitis, (2) understand AFS pathophysiology, (3) recognize AFS clinical presentation, (4) prepare an effective treatment and follow-up strategy, and (5) avoid diagnostic and treatment pitfalls.

DATA SOURCES

All English language MEDLINE articles that cross-referenced allergy, fungal, and sinusitis from 1983-present. Other MESH words referenced included: antibodies, fungal; fungus diseases; IgE; spores, fungal; rhinosinusitis. Additional referenced articles, published abstracts, and conference proceedings were also utilized.

STUDY SELECTION

All case reports, studies, and review articles.

RESULTS

Allergic fungal sinusitis is a distinct form of non-invasive fungal sinusitis. It is under-diagnosed, and incidence varies by region. Dematiaceous fungi predominate. In the southwestern United States, Bipolaris spicifera is the most common cause. Patients present with nasal polyps, rhinosinusitis, and occasionally proptosis. CT scans show hypertrophic sinusitis and often hyperattenuating allergic mucin within the sinus cavities. Extra-sinus extension of disease is common. Surgical histopathology shows eosinophilic-lymphocytic mucosal inflammation and inspissated allergic mucin containing non-invasive fungal hyphae. All patients are atopic and have positive allergy skin tests to the AFS organism. Total serum IgE levels are usually elevated. AFS immunopathophysiology is analogous to allergic bronchopulmonary aspergillosis. Treatment requires surgery, postoperative oral corticosteroids (OCS), and aggressive allergy management including allergen immunotherapy. Oral corticosteroids reduce disease activity and forestall the need for recurrent sinus surgery. Postoperative changes in total serum IgE mirror the clinical status and may predict disease recurrence. Patients should be cooperatively followed by the medical specialist and surgeon because early sinus surgery for recurrence, together with aggressive medical management, gives the best outcome.

CONCLUSIONS

Allergic fungal sinusitis is a new allergic disorder with recognizable clinical and histopathologic findings. Treatment requires aggressive allergy management, postoperative OCS, monitoring of total serum IgE, and medical/surgical co-management.

Overview of basic medical mycology

To introduce the general mycologic aspects of fungal rhinosinusitis, this article reviews, in brief, the biology of fungi and the principles of fungal pathogenesis. A glossary of frequently used mycologic terms is provided. The basis of fungal classification and strategies for the diagnosis of mycotic infections are summarized. The morphologic criteria for the identification of the common etiologic agents of rhinosinusitis are presented.

Allergic fungal rhinosinusitis: pathophysiology, epidemiology, and diagnosis

Allergic fungal rhinosinusitis (AFRS) is believed to have a cause similar to allergic bronchopulmonary aspergillosis (ABPA). Both are thought to be mediated by both type I (IgE) and type III (IgE-antigen immune complexes) Gell and Coombs reactions. ABPA patients also exhibit unique characteristics, such as HLA-DR2 or HLA-DR5 genotypes, and elevated suppressor T cell activity. While the pathophysiology of AFRS is similar histopathologically, similar immunologic studies have not been as well documented. Most cases of AFRS involve dematiaceous fungi, rather than Aspergillus. A suggested laboratory work-up for the disease is presented.

Geographic variation in allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

Aspergillus and other moulds in the air of Kuwait

A one-year survey was carried out to study the aerial prevalence of Aspergillus species and other moulds in the outdoor and indoor environments of Kuwait. Petri plates containing rose-Bengal medium were exposed for 20 minutes twice a month using a six-stage Andersen air sampler at the pre-determined sites. The exposed plates were incubated at 28 degrees C +/- 1 degree C up to 5 days and colonies were enumerated and identified by colonial and microscopic morphology. The data revealed that Aspergillus species were the predominant component (27.7%) of the outdoor aerospora of Kuwait and A. fumigatus alone accounted for 21.3% of the total aspergilli. In contrast, Cladosporium species formed the major component of the indoor aerospora (22.8%), followed by Aspergillus species (20.9%), Penicillium species (14.6%), and Bipolaris species (10.6%). A comparison of the fungi recorded in the outdoor and in the indoor air revealed that Aspergillus, Alternaria and Fusarium were significantly higher in the outdoor environment, whereas Cladosporium, Penicillium, and Bipolaris were significantly higher in the indoor environment. The relative prevalence of Aspergillus species and other moulds in the outdoor and indoor air of Kuwait was as follows: A. fumigatus 5.9 and 9.8%, A. flavus 4.9 and 3.9%, other aspergilli 16.8 and 7.0%, Alternaria species 19.8 and 7.9%, Cladosporium species 13.7 and 22.8%, Penicillium species 7.6 and 14.6%, and other moulds 31.2 and 34.1%, respectively. During the study, 25 different genera were identified, indicating a wide diversity in the spectrum of local fungal aerospora. The study provides useful information on the prevalence of allergenic fungi in the outdoor and indoor environments of Kuwait.