Brazilian guideline for the use of immunobiologicals in chronic rhinosinusitis with nasal polyps ‒ 2024 update

INTRODUCTION

Biologics targeting type 2 inflammation have revolutionized the way we treat patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). Particularly in severe and difficult-to-control cases, these drugs have provided a new reality for these patients, allowing for the effective and safe treatment of extensive diseases that were not completely managed with the typical strategy of surgery and topical medications.

OBJECTIVES

The experience achieved with the approval of these medications by ANVISA for use in CRSwNP and the knowledge obtained regarding outcomes, adverse effects, and the ideal patient profile prompted the update of the previously published guideline, with a detailed review of the most recent scientific literature, the personal experiences of experts, and the adaptation to the reality of the Brazilian healthcare system, both public and private.

RESULTS

We proposed a new eligibility criterion for biologics in patients with CRSwNP based on four pillars of indication: the impact of the disease on the patient's life, whether in the presence of specific symptoms or in overall quality of life; the extent of sinonasal disease; the presence of type 2 comorbidities, considering other associated diseases that may also benefit from anti-T2 biologics, and the presence of biomarkers to define type 2 inflammation, especially those associated with worse disease prognoses.

CONCLUSIONS

This innovative and pioneering method has two major advantages. First, it ensures a comprehensive evaluation of patients; second, it is flexible, as advancements in our understanding of the disease and changes in cost-effectiveness can be addressed by simply adjusting the required score for indication, without the need to modify the entire evaluation scheme.

Assessment of Immune and Clinical Response in Patients with Mucosal Leishmaniasis Treated with Pentavalent Antimony and Pentoxifylline

Mucosal leishmaniasis (ML) is a severe form of tegumentary leishmaniasis associated with a persistent inflammatory response. High levels of TNF, IFN-γ, CXCL9 and CXCL10 are found in ML patients, and the association of pentoxifylline with antimony is more effective in decreasing the healing time in ML patients when compared to antimony alone. The present study aimed to investigate the existence of a correlation between cytokine and chemokine production and ML severity and evaluate the potential value of cytokine and chemokine production as marker of therapeutic response in ML patients. This prospective study included 86 subjects in an area of endemic Leishmania braziliensis transmission. Patients diagnosed with ML were classified into clinical stages ranging from I to V according to disease severity. TNF, IFN-γ, CXCL9 and CXCL10 levels were quantified in the supernatant of the mononuclear cell cultures by ELISA before and after treatment with antimony alone or antimony plus pentoxifylline. The median TNF level in the group with mild disease (Stages I-II) was 1064 pg/mL (142-3738 pg/mL), while, in the group with moderate or severe disease (Stages III-V), it was 1941 pg/mL (529-5294 pg/mL) (p = 0.008). A direct correlation was observed between ML clinical severity and levels of TNF production (r = 0.44, p = 0.007). Patients who were treated with antimony and pentoxifylline healed significantly faster than those treated with antimony alone (52 vs. 77 days, hazard ratio = 0.60; 95% confidence interval = 0.38-0.95, p = 0.013). Therapeutic failure was higher in the group that received antimony alone (25% vs. 7%; p = 0.041). There was a significant decrease in CXCL9 after therapy of ML in both groups (p = 0.013; p = 0.043). TNF levels are associated with the severity of mucosal diseases, and pentoxifylline associated with antimony should be the recommended therapy for ML in countries where liposomal amphotericin B is not available.

High Anti-Leishmania IgG Antibody Levels Are Associated With Severity of Mucosal Leishmaniasis

Background

Mucosal leishmaniasis (ML), the most inflammatory form of tegumentary leishmaniasis, is predominantly caused by Leishmania braziliensis. The disease is characterized by the development of lesions, mainly in the nasal mucosa. An exacerbated inflammatory response has been associated with the presence of destructive and disfiguring lesions, with stages of severity ranging from small nodulations to the complete destruction of the nasal pyramid architecture. As Leishmania is an intracellular parasite, most immunological studies have emphasized the cell-mediated immune response, while relatively few studies aimed to investigate the role antibodies in protection against, or the pathology of ML.

Methods

Patients with a confirmed diagnosis of ML were classified according to clinical staging criteria. Serum levels of Leishmania-specific IgG, IgG1 and IgG2 antibodies were determined by ELISA before and after treatment with antimony or antimony plus pentoxifylline.

Results

Patients in stages IV and V produced higher concentrations of IgG and IgG1 antibodies when compared to those in stage I and II. Significant reductions were seen in the concentrations of IgG and IgG2 antibodies in most patients who responded well to treatment.

Conclusions

Our data demonstrate an association between IgG antibody titers and the severity of mucosal disease. The observed reduction in antibody production after successful treatment in most patients preliminarily indicates that these tests can be used to aid in the assessment of therapeutic response.

Guideline for the use of immunobiologicals in chronic rhinosinusitis with nasal polyps (CRSwNP) in Brazil

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The use of immunobiologicals is an option for the management of patients with chronic rinosinusitis with nasal polyps (CRSwNP) refractory to conventional treatment.

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The guideline lists the main drugs currently available in Brazil, their indications, and recommendations for use.

Introduction

Severe uncontrolled chronic rhinosinusitis with nasal polyps has a negative impact on an individual’s quality of life. Therefore, new biologics have emerged for use in specific phenotypes of chronic rhinosinusitis, changing the paradigms of its treatment.

Objective

To review the current status of biologic treatment indications in chronic rhinosinusitis.

Methods

The Brazilian Academy of Rhinology brought together different specialists to suggest a course of action, considering its particularities and aspects related to the national reality.

Results

Of particular interest for decision making will be the identification of subgroups of patients refractory to pre-existing treatment options and the construction of a strategy that improves their quality of life, with the best cost-benefit ratio.

Conclusion

The use of biologics is a valid option for treatment in more severe cases. This strategy must be better understood and improved in the future, with more studies and greater clinical experience.

Case Report: Unusual Presentation of Pharyngeal Mucosal Leishmaniasis due to Leishmania (Viannia) braziliensis

Mucosal leishmaniasis (ML) affects predominantly the nose and occurs usually weeks or months after the cure of the primary cutaneous lesion. The pathology of ML is characterized by an exaggerated inflammatory reaction with infiltration of lymphocytes, macrophages, and plasma cells. There is also a paucity of parasites and a strong delayed-type hypersensitivity reaction. Herein, we report a case of a young man who had a large ulcer in his left leg and complained of dysphagia. In nasofibrolaryngoscopy, there were nodular lesions in the oropharynx and rhinopharynx. The skin lesion biopsy showed a chronic inflammation with amastigotes inside macrophages, and DNA of Leishmania braziliensis confirmed the diagnosis of ML in tissue biopsied from the pharynx. The leishmaniasis skin test was negative. Cytokine evaluation showed lack of production of interferon (IFN)-γ, interleukin (IL)-1β, and IL-17 with enhancement of these cytokine levels after cure.

Mucosal leishmaniasis: A Retrospective Study of 327 Cases from an Endemic Area of Leishmania (Viannia) braziliensis

Mucosal leishmaniasis (ML) is observed only in about 3% of patients with American tegumentary leishmaniasis (ATL) but has a high potential for destructive, disfiguring, and disabling sequelae. Prior reports of clinical and epidemiologic features of ML are limited by small numbers of cases. In this study, we evaluated changes in the demographic features and clinical presentation of ML in an endemic area of Leishmania braziliensis transmission over a period of 20 years. The charts of 327 patients with ML diagnosed between 1995 and 2014 were reviewed. The majority of patients (67%) were male. Age ranged from 8 months to 103 years, with a median age of 38.5 years (interquartile range: 22-58 years). The greatest number of patients was between 19 and 39 years (31%). Over the study period, there was an increase in patients with ML more than 60 years of age, an increase in ML with concomitant cutaneous lesions, a decrease in the period of time between the documentation of cutaneous lesions and the diagnosis of mucosal disease, and an increase in the frequency of patients presenting with stage I and V of ML. Moreover, there was a positive correlation between severity of mucosal disease and both age and the period of time between cutaneous lesion and mucosal disease. Response to therapy of ML remained similar over a period of 20 years. Despite the improvement in medical care during the study period, the prevalence of ML did not change and severe disease continues to be a major challenge for the management of these patients.

A proposed new clinical staging system for patients with mucosal leishmaniasis

Mucosal leishmaniasis (ML) occurs mainly in areas where Leishmania braziliensis is transmitted. It affects predominantly the nasal mucosa and, in more severe forms, can lead to significant tissue destruction. There is no standard method for grading the severity of disease. We categorised 50 patients with ML according to a proposed new clinical staging system. Their age ranged from 10 to 86 y (mean ± SD: 36 ± 16 y) and 43 (86%) patients were male. The different degrees of evolution of mucosal disease, from the initial stage to the more severe long-term cases, enabled ML to be graded into five stages. Stage I is characterised by nodular lesions of the mucosa without ulceration. Stage II is represented by superficial mucosal ulcerations with concomitant fine granular lesions. Stage III is characterised by deep mucosal ulcerations with granular tissue formation. In stage IV there are irreversible lesions leading to perforation of the cartilaginous nasal septum with necrosis. In stage V the nasal pyramid is compromised with alterations of facial features as a consequence of severe tissue destruction. These stages may be useful in characterising the severity of the lesion and optimising therapeutic outcome.

Brown tumor of the facial bones: case report and literature review

Brown tumor, an uncommon focal giant-cell lesion, arises as a direct result of the effect of parathyroid hormone on bone tissue inpatients with hyperparathyroidism. The initial treatment involves the correction of hyperparathyroidism, which usually leads to tumor regression. We report a case of brown tumor of the right nasal fossa in a 71-year-old woman. The tumor had caused nasal obstruction and epistaxis. Laboratory evaluation revealed that the patient had primary hyperparathyroidism. Anatomicopathologic investigation revealed the presence of a giant-cell tumor We performed a partial parathyroidectomy, but the tumor in the right nasal fossa failed to regress. One year later we performed surgical resection of the lesion. The patient recovered uneventfully, and she remained asymptomatic and recurrence-free at the 1-year follow-up. Facial lesions with histologic features of a giant-cell tumor should be evaluated from a systemic standpoint. Hyperparathyroidism should always be investigated by laboratory tests because most affected patients are asymptomatic. Surgical resection of a brown tumor should be considered if the mass does not regress after correction of the inciting hyperparathyroidism or if the patient is highly symptomatic.

Brown Tumor of the Facial Bones: Case Report and Literature Review

Brown tumor, an uncommon focal giant-cell lesion, arises as a direct result of the effect of parathyroid hormone on bone tissue in patients with hyperparathyroidism. The initial treatment involves the correction of hyperparathyroidism, which usually leads to tumor regression. We report a case of brown tumor of the right nasal fossa in a 71-year-old woman. The tumor had caused nasal obstruction and epistaxis. Laboratory evaluation revealed that the patient had primary hyperparathyroidism. Anatomicopathologic investigation revealed the presence of a giant-cell tumor. We performed a partial parathyroidectomy, but the tumor in the right nasal fossa failed to regress. One year later, we performed surgical resection of the lesion. The patient recovered uneventfully, and she remained asymptomatic and recurrence-free at the 1-year follow-up. Facial lesions with histologic features of a giant-cell tumor should be evaluated from a systemic standpoint. Hyperparathyroidism should always be investigated by laboratory tests because most affected patients are asymptomatic. Surgical resection of a brown tumor should be considered if the mass does not regress after correction of the inciting hyperparathyroidism or if the patient is highly symptomatic.

Primary Non-Hodgkin's Lymphoma of the Frontal Sinus: Case Report and Review of the Literature

Non-Hodgkin's lymphoma of the sinonasal tract is an uncommon lesion, representing 1.5 to 15% of all lymphomas. Most cases of primary non-Hodgkin's lymphoma of the sinonasal tract occur in the maxillary sinus, ethmoid sinus, and nasal cavity; its occurrence in the frontal sinus is extremely rare. We report a case of primary type B non-Hodgkin's lymphoma of the frontal sinus in a 43-year-old man. The patient complained of frontal headaches that had not improved with analgesic drugs, and he presented with a frontal bulge that involved the left upper eyelid; the bulge had progressively enlarged over a 3-month period. A biopsy of the mass identified the type B non-Hodgkin's lymphoma. Immunohistochemical study not only confirmed the histologic type of the tumor, it also provided some important information about the primary tumor site. Advances in immunohistochemistry have shown that type B non-Hodgkin’s lymphoma is more common in North American and European patients, whereas subtype T is more common in Asians and in some Latin Americans. The treatment of this condition is still controversial, but the combination of radiotherapy and chemotherapy has yielded the best results in all stages of the disease.

Primary non-Hodgkin's lymphoma of the frontal sinus: case report and review of the literature

Non-Hodgkin's lymphoma of the sinonasal tract is an uncommon lesion, representing 1.5 to 15% of all lymphomas. Most cases of primary non-Hodgkin's lymphoma of the sinonasal tract occur in the maxillary sinus, ethmoid sinus, and nasal cavity; its occurrence in the frontal sinus is extremely rare. We report a case of primary type B non-Hodgkin's lymphoma of the frontal sinus in a 43-year-old man. The patient complained of frontal headaches that had not improved with analgesic drugs, and he presented with a frontal bulge that involved the left upper eyelid; the bulge had progressively enlarged over a 3-month period A biopsy of the mass identified the type B non-Hodgkin's lymphoma. Immunohistochemical study not only confirmed the histologic type of the tumor, it also provided some important information about the primary tumor site. Advances in immunohistochemistry have shown that type B non-Hodgkin's lymphoma is more common in North American and European patients, whereas subtype T is more common in Asians and in some Latin Americans. The treatment of this condition is still controversial, but the combination of radiotherapy and chemotherapy has yielded the best results in all stages of the disease.

Sphenochoanal polyp: diagnose and treatment

Choanal polyps (CP) are benign mucous tumours that usually originate in the mucosa of the maxillary sinus, and hence are termed antrochoanal polyps. CP rarely originates in the mucosa of other nasal structures and paranasal sinuses. The purpose of this brief clinical communication is to present six cases of CP originating in the sphenoidal sinus and termed sphenochoanal polyps (SCP).