Complete surgical resection and short-term survival in acute invasive fungal rhinosinusitis

Prognostic Factors for Survival Using a Clinical Severity Staging System Among Patients With Acute Invasive Fungal Sinusitis

Importance

Despite the aggressive progression of fulminant acute invasive fungal sinusitis (AIFS), data on prognostic factors have been disparate, hindering the development of a staging system. A composite staging system may improve prognostication for patient counseling and conduct of clinical research.

Objective

To identify prognostically important factors in AIFS and to incorporate the factors into a comprehensive Functional Severity Staging System and Clinical Severity Staging System.

Design, Setting, and Participants

This retrospective cohort study included adult patients diagnosed with pathology-proven AIFS from June 1, 1992, to December 31, 2022, at Washington University Medical Center and Barnes-Jewish Hospital, a tertiary care center in St Louis, Missouri. Data were analyzed from April to July 2023.

Main Outcome and Measures

Sequential sequestration and conjunctive consolidation was used to develop a composite staging system to predict 6-month overall survival.

Results

Of 71 patients with pathology-proven AIFS over the 30-year period, the median (range) age of the cohort was 56 (19-63) years, and there were 47 (66%) male patients. The median (range) follow-up time was 2 (0-251) months. There were 28 patients alive within 6 months, for a 39% survival rate. Symptoms, comorbidity burden, and presence and duration of severe neutropenia were associated with 6-month survival and were consolidated into a 3-category Clinical Severity Staging System with 6-month survival of 75% for stage A (n = 16), 41% for stage B (n = 27), and 18% for stage C (n = 28). The discriminative power of the composite staging system was moderate (C statistic, 0.63).

Conclusion and Relevance

This cohort study supports the clinical importance of symptomatology, comorbidity burden, and prolonged severe neutropenia at the time of AIFS presentation. The composite clinical staging system may be useful for clinicians when counseling patients with AIFS and conducting clinical research.

Fourteen cases of acute invasive fungal rhinosinusitis: is there a place for less aggressive surgical treatment?

PURPOSE

Acute invasive fungal rhinosinusitis (AIFRS) is a rare, fulminant, angio-invasive infection with high mortality rate. Treatment of AIFRS includes aggressive surgical debridement combined with antifungal agents and treatment of the underlying disease. The aim of this study is to report our experience with this often fatal disease and estimate the long-term survival of AIFRS patients with more conservative surgery.

METHODS

A retrospective study was performed on immunocompromised adults with AIFRS from January 2011 to December 2020. The diagnosis was histologically confirmed by tissue fungus invasion. We analyze epidemiological and microbiological findings, the underlying disease and discuss our patients' treatment plan and long-term survival.

RESULTS

Fourteen patients were included in the study. Mean age was 53.8 ± 18.9 years. The underlying disease was hematologic malignancy in nine patients, diabetes mellitus in three, aplastic anemia in one, and renal/liver failure in one. Leukopenia was not significantly correlated with outcome or survival. Histological and culture findings revealed that Mucor/Rhizopus were the causative organisms in nine cases. All patients received systemic antifungal therapy. Surgery was performed in nine patients (endoscopic for all patients, combined in three with an external approach). Overall survival was 35.7% as five patients survived, two who underwent surgery, and three who were treated non-surgically. Nine patients died, two from AIFRS after central nervous system involvement and seven from their primary disease, free of fungi. Older individuals and patients with hematologic malignancies had a worse outcome.

CONCLUSION

Early surgical debridement, antifungal agents, and treatment of the underlying disease remain the cornerstones of AIFRS management. Prognosis is overall defined by the underlying disease and in some selected cases, medical treatment alone could be a reasonable option.

Optimizing Surgical Management of Acute Invasive Fungal Sinusitis

Objective

Early surgical debridement is vital for favorable outcomes in acute invasive fungal sinusitis (AIFS). Our study aimed to propose guidelines with tailored, conservative surgical procedures based on areas of involvement and evaluate their usefulness in avoiding repeated debridement.

Methods

This retrospective observational study was conducted on 150 AIFS patients operated on with the proposed surgical guidelines from May to June 2021 at a tertiary care hospital. Data including demography, comorbidities, surgical procedures, revision surgery, and outcome were collected and analyzed.

Results

All 150 patients underwent bilateral endoscopic sinonasal debridement. Among them, 108 patients (72%) had current or recent coronavirus disease (COVID) infection. Ninety-two patients (61.3%) required additional procedures based on disease extent. Twenty patients (15.4%) required revision debridement because of progressive or recurrent disease. Mean age of this group was 46.15 (standard deviation ±11.2) years with a strong male predominance (9:1). Seventeen had diabetes mellitus, 12 suffered from active COVID-19 infection and six had received corticosteroids. None of the 31 patients who had recovered from COVID-19 or had no comorbidities required revision surgery. Age, gender, and comorbidities were not significant predictors for revision surgery. Fourteen patients (70%) underwent second surgery within one month of primary surgery. Predominant disease locations were alveolus and palate (55% each), and in 80% the site was uninvolved at primary surgery. The most common revision procedure was inferior partial maxillectomy (60%). At follow-up, all were asymptomatic with no evidence of disease.

Conclusion

The proposed surgical guidelines for AIFS allow for adequate surgical debridement with preservation of optimum functional status. Low revision surgery rates and good outcomes with minimal morbidity validate its usefulness.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations

BACKGROUND

Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated.

RESULTS

A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains.

CONCLUSION

Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

Diagnostic and therapeutic strategies of acute invasive fungal rhinosinusitis

Acute invasive fungal rhinosinusitis (AIFR) is a rare disease, but the prognosis is by no means ideal. Pathologically, fungal infection is not only located in the sinus cavity, but also invades the sinus mucosa and bone wall, the surrounding structures and tissues such as the orbit and anterior skull base are often compromised and are accompanied with intracranial and extracranial complications. Despite decades of efforts, acute invasive fungal rhinosinusitis remains a devastating disease, the mortality of the disease continues to hover around 50%. The main impediments to improving the prognosis of acute invasive fungal rhinosinusitis are the difficulties of early diagnosis and the rapid reversal of immune insufficiency. Moreover, aggressive surgery combined with systemic antifungal therapy are significant positive prognostic factors as well. Progress and standardization of AIFR treatment protocols have been limited by the scarcity of the disease and the absence of published randomized studies. Therewith, how to improve the therapeutic outcome and reduce the mortality rate has always been a challenging clinical discussion. We have summarized the relevant case series and literature from the recent years, management with optimal diagnostic and curative strategies are reviewed.

Pediatric Invasive Fungal Rhinosinusitis: A Comprehensive Analysis of Prognostic Factors for Survival

OBJECTIVE

Pediatric invasive fungal rhinosinusitis (IFS) is a devastating infection that manifests almost exclusively in immunocompromised children. The goal of this work was to determine which clinical features carry prognostic value for survival.

METHODS

A retrospective review of children with a histopathological diagnosis of IFS was performed at an academic tertiary care institution from 1990 to 2021. Clinical variables were collected to generate survival and life-table estimators at 6-months and 1-year.

RESULTS

Eighteen patients were included in this analysis, with a mean age of 9.8 years (range, 1-17 years). Most children were neutropenic (n = 15, 83.3%), with acute lymphoblastic leukemia (n = 10, 55.6%) representing the most common primary diagnosis. A mean of 3.2 operations (range 1-7 operations) was performed per patient for either mucormycosis (n = 10, 55.6%) or aspergillosis (n = 8, 44.4%). The mean time to absolute neutrophil count recovery was 65.8 days (range 20-137 days), with a 6-month and 1-year survival rate of 47.6% and 41.7%, respectively. Gross total resection (p = 0.006, p < 0.001), number of antifungals (p = 0.0004, p = 0.0003), and total operation number (p = 0.0032, p = 0.0035), served as positive prognostic factors for 6-month and 1-year survival. Conversely, altered mental status (p = 0.0026), cerebral involvement (p = 0.0010), cranial neuropathies (p < 0.0001), hyperglycemia (p = 0.0445, p = 0.0208), and intensive care unit status (p = 0.0013) served as negative prognostic factors for 6-month and 1-year survival.

CONCLUSION

Several key elements were identified and found to play a vital role in influencing survival for pediatric IFS. Early diagnosis, prompt medical therapy, and aggressive surgical intervention remain at the forefront in the treatment of this complex opportunistic infection.

LEVEL OF EVIDENCE

IV Laryngoscope, 2022.

Changing Trends in the Survival of Immunosuppressed Children with Invasive Fungal Rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis has been associated with high mortality rates.

OBJECTIVE

We aimed to explore the contribution of novel detection and treatment methods on the outcome of immunosuppressed children with acute invasive fungal rhinosinusitis.

METHODS

The records of all children with a hematologic or oncologic disease who developed acute invasive fungal rhinosinusitis between 2005-2020 were reviewed.

RESULTS

Thirty-four patients were included. Aspergillosis and mucormycosis were diagnosed in 20 patients (59%) and 12 patients (35%), respectively. Panfungal polymerase chain reaction (PCR) was associated with a change of treatment in 36% of patients. A more aggressive surgical approach as well as treatment with liposomal amphotericin B and novel antifungals were adopted in recent years. Overall, 26% of patients died of disease, however no disease-specific death occurred since 2012. Diagnosis using panfungal PCR (p  =  .04) and treatment with novel antifungal medications (p  =  .017) were significantly associated with disease-specific survival.

CONCLUSION

Enhanced fungal detection using panfungal PCR and treatment with novel antifungal agents, combined with rapid diagnosis and treatment, aggressive surgical approach and better control over the underlying oncological disease, may significantly improve the outcome of immunosuppressed children with acute invasive fungal rhinosinusitis.

Invasive Fungal Rhinosinusitis with and without Orbital Complications: Clinical and Laboratory Differences

Background: Invasive fungal rhinosinusitis (IFS) is a rare but often fatal disease. There are limited studies regarding IFS with orbital complications (IFSwOC). The present study aimed to identify the clinical signs associated with IFSwOC and prognosticators of the disease. Methods: A retrospective case series was conducted of patients histopathologically confirmed IFS or fungal rhinosinusitis with clinically apparent neuro-orbital complications who underwent surgery between 2008 and 2018. Demographic data, presenting symptoms and signs, culture data, laboratory results, and patient outcomes were obtained from medical records. Results: A total of 38 patients were identified, including 9 patients with IFSwOC, and 29 patients with IFS without orbital complications (IFSsOC). The clinical signs associated with developing orbital complications include headache, fever, sphenoid sinus, or posterior ethmoid sinus involvement, CRP level ≥ 1.025 mg/dL, or ESR level ≥ 46.5 mm/h. In IFSwOC group, male, posterior ethmoid sinus involvement, WBC count ≥ 9000 μL, CRP level ≥ 6.91 mg/dL, or ESR level ≥ 69 mm/h were correlated with a significantly poorer prognosis. Conclusion: IFS patients with sphenoid or posterior ethmoid sinus involvement, headache or fever as presenting symptoms, elevated CRP, and ESR level were at risk of developing orbital complications. Timely surgical debridement followed by systemic antifungal treatment may improve treatment outcomes.

Fusarium rhinosinusitis post chimeric antigen receptor T-cell therapy

•

Infectious complication following chimeric antigen receptor T-cell (CAR-T) therapy is not uncommon.

•

Our case illustrated significant findings of acute invasive fungal rhinosinusitis (AIFR) from Fusarium species after CAR-T therapy.

•

The diagnosis of AIFR is usually challenging due to unrecognized clinical presentation leading to significant morbidity.

Chimeric antigen receptor T-cell (CAR-T) therapy is a novel treatment for various types of hematologic malignancy. We presented a case of refractory diffuse large B cell lymphoma patient who developed acute invasive fungal rhinosinusitis (AIFR) from Fusarium species after CAR-T therapy. Our photos illustrated the classic clinical, endoscopic, and histopathologic findings of AIFR.

Perioperative Indicators of Prognosis in Acute Invasive Fungal Sinusitis

Objective

The purpose of this study is to identify perioperative independent prognostic factors that are available to the consulting team to aid in determining prognosis in patients with acute invasive fungal sinusitis.

Study Design

Retrospective chart review of patients with biopsy-proven acute invasive fungal sinusitis from 2015 to 2018.

Setting

Academic tertiary care center.

Methods

Twenty-one patients were included from our single-center retrospective review. Kaplan-Meier graphs were created, and the Breslow test used to compare the curves to obtain P values. A univariate Cox regression analysis was performed on the data that were significant at 3 months from diagnosis.

Results

Twenty-one patients were included, and 17 (76%) had an underlying hematologic malignancy. Overall survival was 71% and 52% at 1 and 3 months, respectively, and 94% of patients with hematologic malignancy had an absolute neutrophil count ≤1 at diagnosis. Absolute neutrophil count values and fungal species were not associated with a difference in prognosis. Factors associated with decreased survival included current smoking and the absence of a rhinologist on the treatment team at the initial or subsequent debridement (hazard ratio, 3.03). Laboratory values such as beta-D-glucan and galactomannan were assessed in addition to disease extension at diagnosis.

Conclusion

This study presents a retrospective review of a single institution’s experience with acute invasive fungal sinusitis. Subspecialty level of care likely improves overall survival in these patients, whereas current smoking may imply a worse prognosis.

Acute Invasive Fungal Sinusitis: A 30-Year Review of Pathology Practice and Possible Utility of the DiffQuik® Stain

Acute invasive fungal rhinosinusitis (AIFRS) is a fulminant disease with a high mortality rate. Here, we review the clinical and pathologic features of AIFRS over a 30-year period at a tertiary-care academic center focusing on diagnostic practice, especially the use of intra-operative consultation (IOC). A 1-year trial of intraoperative staining with DiffQuik® (DQ) was also assessed. There were 202 cases from 104 patients with AIFRS. The incidence of AIFRS increased over time (6.8 per year in the past decade versus 1.9 before 2009) as did the number of IOCs per case (2.4 per case in the past decade versus 0.6 before 2009). Disagreement between final diagnosis and IOC was seen in 8.3 % of patients, and the block-by-block error rate was 14.9 %. Fusarium was the most common fungus identified. An attempt to categorize the fungal organism based on histopathology was performed in 85.6 % of patients, with 91 % agreement with microbial cultures or PCR. Fungal hyphae were subjectively easier to identify on DQ stained cryostat sections compared to on routine hematoxylin and eosin stained sections and hyphae were identified in all 5 blocks in which organisms were present. The increasing incidence of AIFRS and expanding use of IOC indicate a need to improve and standardize the diagnostic protocol. The use of DQ as visual aid in IOC for AIFRS may be useful.

An internally validated diagnostic tool for acute invasive fungal sinusitis

BACKGROUND

Acute invasive fungal sinusitis (AIFS) is a potentially life-threatening diagnosis in immunocompromised patients. Identifying patients who could benefit from evaluation and intervention can be challenging for referring providers and otolaryngologists alike. We aimed to develop and validate an accessible diagnostic tool to estimate the probability of AIFS.

METHODS

Retrospective chart review from 1999 to 2017 identified all patients evaluated for possible AIFS at a tertiary care center. AIFS was diagnosed by pathologic confirmation of fungal tissue angioinvasion. Stepwise selection and univariate logistic regression were used to screen risk factors for a multivariable predictive model. Model performance was assessed using Tukey's goodness-of-fit test and the area under the receiver operator characteristic curve (AUC). Model coefficients were internally validated using bootstrapping with 1000 iterations.

RESULTS

A total of 283 patients (244 negative controls, 39 with AIFS) were included. Risk factors in our final diagnostic model included: fever ≥38°C (log-odds ratio [LOR] 1.72; 95% CI, 0.53 to 2.90), unilateral facial swelling, pain, or erythema (LOR 2.84; 95% CI, 1.46 to 4.23), involvement of the orbit or pterygopalatine fossa on imaging (LOR 3.02; 95% CI, 1.78 to 4.26), and mucosal necrosis seen on endoscopy (LOR 5.52; 95% CI, 3.81 to 7.24), with p < 0.01 for all factors. The model had adequate goodness of fit (p > 0.05) and discrimination (AUC = 0.96).

CONCLUSION

We present an internally validated diagnostic tool to stratify the risk for AIFS. The estimated risk may help determine which patients can be observed with serial nasal endoscopy, which ones could be biopsied, and which ones would benefit from immediate surgical intervention.

Benefit of Endoscopic Surgery in the Management of Acute Invasive Skull Base Fungal Rhinosinusitis

Objective  This article aims to characterize 14 patients who underwent purely endoscopic surgical debridement of acute invasive skull base fungal rhinosinusitis, and to evaluate postoperative outcomes and risk for recurrence. Design  Retrospective cohort study. Setting  Tertiary single-institution neurosurgery department. Participants  We performed a retrospective analysis of all patients with skull base fungal infections treated with a purely endoscopic surgical approach at Mount Sinai Hospital from 1998 to 2018. Main Outcome Measures  Clinical presentation, number of recurrences, and mortality rate. Results  The most common underlying medical comorbidities were hematologic malignancy in 8 (57.1%) patients and poorly controlled diabetes mellitus in 7 (50%) patients. Presenting symptoms included headache (50%), eye pain (35.7%), facial pain (28.6%), visual changes (21.4%), and nasal congestion (14.3%). The fungal organisms identified on culture were Aspergillus (42.9%), Mucorales (28.6%), Fusarium (14.3%), Penicillium (7.1%), and unspecified (7.1%). Eight (57.1%) patients developed recurrence and required multiple surgical debridements. Patients who had only a hematologic malignancy were more likely to require multiple surgical debridements compared with those who did not have a hematologic malignancy or those who had both hematologic malignancy and underlying diabetes mellitus ( p  = 0.03). The mortality rate from surgery was 42.9%. Conclusion  Surgical endoscopic intervention is an option for definitive management of acute invasive skull base fungal rhinosinusitis; however, postoperative mortality and risk of recurrence requiring additional surgical interventions remains high. Patients with hematologic malignancy may be more susceptible to recurrent infection requiring multiple surgical debridements. We recommend early aggressive multimodal treatment. Multiple debridements may be warranted in most cases; close clinical surveillance is needed during neurosurgical intervention.