Rinosinusitis micótica alérgica con destrucción de base de cráneo / Allergic fungal rhinosinusitis with skull base destruction

La sinusitis micótica alérgica es una enfermedad inflamatoria de la mucosa rinosinusal producida por hongos que pueden aislarse de la cavidad de nasal de individuos sanos. Se produce indirectamente por los hongos que actúan como antígeno y desencadenan una reacción inmunológica mediada por IgE que origina pólipos y una secreción mucosa espesa con detritus e hifas denominada mucina. Su presentación clínica más frecuente es una sinusitis crónica unilateral o bilateral con pólipos. Con menos frecuencia, las sustancias originadas por la desgranulación de los eosinófilos producen remodelación o destrucción ósea y la sinusitis puede simular una neoplasia. Se describe el caso clínico de un paciente que padeció una sinusitis micótica alérgica con destrucción ósea masiva de la base del cráneo y que tuvo extensión intracraneal extradural e intraorbitaria de la enfermedad. Fue tratado con éxito mediante cirugía y corticoides. (AU)

Allergic fungal sinusitis is an inflammatory disease of the rhinosinusal mucosa caused by fungi that can be isolated from the nasal cavity of healthy individuals. The pathology is produced indirectly by the fungus that acts as an antigen and triggers an IgE-mediated allergic reaction that causes polyps and a thick mucous discharge with detritus and hyphae called mucin. Its most common clinical presentation is unilateral or bilateral chronic sinusitis with polyps. Less commonly, substances originated by the degranulation of eosinophils cause bone remodeling or destruction, and sinusitis can simulate a neoplasia. We describe the clinical case of a patient who suffered from allergic fungal sinusitis with massive bone destruction of the skull base and who had intracranial, extradural and intraorbital extension of the disease. He was successfully treated with surgery and corticosteroids.Key words: allergic fungal sinusitis, intracranial extension, endoscopic surgery, transorbital transpalpebral approach. (AU)

Refractory Allergic Fungal Sinusitis and its Medical Management in a Tertiary Hospital

Background: Allergic fungal sinusitis (AFS) is the most common form of fungal sinus disease with a high rate of recurrence ratedespite the advent of advanced endoscopic sinus surgery and usage of steroids. Refractory AFS is defined as a condition ofallergy due to fungal antigenic elements not amenable to surgical removal or prolonged medical management. Oral itraconazoleis an antifungal agent that seems to be benefit to the patients with refractory AFS. Hence, this study was conducted to comparethe outcome of AFS after addition of oral itraconazole to the treatment protocol.Aim of the Study: The aim of the study was to evaluate the acceptance and usefulness of itraconazole, an oral antifungaldrug, in the treatment of refractory AFRS.Materials and Methods: A total of 84 patients with refractory AFS were included in this study. The medical records of these patientswere retrieved from the medical records section and analyzed. A detail history of the AFS was elicited and demographic data weretabulated. Nasal endoscopy was done before and 3 months after the itraconazole therapy and the findings were classified according toLund-Kennedy endoscopic grading system, Scoring from 7 to 10 was graded as severe; scoring from 4 to 6 was graded as moderateand 1 to 3 as mild grade. Itraconazole was administered in the form of capsule 100 mg 2 times daily for 3 months. Prior hepaticfunction and renal function tests were undertaken for all the patients. All the data were analyzed using standard statistical methods.Observations and Results: Among the 84 patients, there were 52 (61.90%) males and 32 (38.09%) females with a male tofemale ratio of 1.6:1. The patients were aged between 18 years and 78 years with a mean age of 33.45 ± 4.15 years. Conversionof severe grade patients to mild grade following itraconazole therapy was note; post-treatment findings were severe in 5 patients,moderate in 1, and mild in 78 patients.Conclusions: Itraconazole may be useful as an adjunct in the management of AFRS. However, more studies, including aprospective randomized clinical trial, are required to determine if itraconazole is effective in the management of AFRS.

Allergic Bronchopulmonary Aspergillosis: A Perplexing Clinical Entity

In susceptible individuals, inhalation of Aspergillus spores can affect the respiratory tract in many ways. These spores get trapped in the viscid sputum of asthmatic subjects which triggers a cascade of inflammatory reactions that can result in Aspergillus-induced asthma, allergic bronchopulmonary aspergillosis (ABPA), and allergic Aspergillus sinusitis (AAS). An immunologically mediated disease, ABPA, occurs predominantly in patients with asthma and cystic fibrosis (CF). A set of criteria, which is still evolving, is required for diagnosis. Imaging plays a compelling role in the diagnosis and monitoring of the disease. Demonstration of central bronchiectasis with normal tapering bronchi is still considered pathognomonic in patients without CF. Elevated serum IgE levels and Aspergillus-specific IgE and/or IgG are also vital for the diagnosis. Mucoid impaction occurring in the paranasal sinuses results in AAS, which also requires a set of diagnostic criteria. Demonstration of fungal elements in sinus material is the hallmark of AAS. In spite of similar histopathologic features, co-existence of ABPA and AAS is still uncommon. Oral corticosteroids continue to be the mainstay of management of allergic aspergillosis. Antifungal agents play an adjunctive role in ABPA as they help reduce the fungal load. Saprophytic colonization in cavitary ABPA may lead to aspergilloma formation, which could increase the severity of the disease. The presence of ABPA, AAS, and aspergilloma in the same patient has also been documented. All patients with Aspergillus-sensitized asthma must be screened for ABPA, and AAS should always be looked for.

Nasal Polyp Due to Aspergillus: A Case Report.

Different studies have found a 6-9% incidence of allergic fungal sinusitis (AFS) among chronic sinusitis patients requiring surgery. Invasive rhinosinusitis due to Aspergillus causing nasal polyposis, bony erosion has been reported. Nasal discharge and nasal obstruction are said to be the commonest presentation. We report the case of a 48-year-old man who presented with complaints of nasal obstruction and foul-smelling nasal discharge from the past 6 months. He was investigated and found to have a nasal polyp involving left maxillary sinus and nasal cavity. Plain X-ray showed no bony involvement.

Allergic Aspergillus sinusitis and its association with allergic bronchopulmonary aspergillosis

Allergic Aspergillus sinusitis (AAS) is a three decade old clinicopathologic entity in which mucoid impaction akin to that of allergic bronchopulmonary aspergillosis (ABPA) occurs in the paranasal sinuses. Features such as radiographic evidence of pansinusitis, passage of nasal plugs and recurrent nasal polyposis in patients with an atopic background is suggestive of AAS. Histopathlogic confirmation from the inspissated mucus is a sine qua non for the diagnosis. Heterogeneous densities on computed tomography of the paranasal sinuses are caused by the 'allergic mucin' in the sinuses. Many patients give a history of having undergone multiple surgical procedures for symptomatic relief. The current approach to treatment appears to include an initial surgical debridement followed by postoperative oral corticosteroids for long durations. Although both ABPA and AAS are classified as Aspergillus-related hypersensitivity respiratory disorders, their co-occurrence appears to be an infrequently recognised phenomenon. This could perhaps be attributed to the fact that these two diseases are often treated by two different specialties. A high index of suspicion is required to establish the diagnoses of ABPA and AAS. All patients with asthma and/or rhinosinusitis along with sensitisation to Aspergillus antigens are at an increased risk of developing ABPA and/or AAS. ABPA must be excluded in all patients with AAS and vice versa. Early diagnosis and initiation of appropriate therapy could plausibly alter the course of the disease processes and prevent the possible development of long term sequelae.

A Case of Allergic Fungal Sinusitis due to Curvularia / 대한임상미생물학회지

Allergic fungal sinusitis (AFS) is a noninvasive form of fungal rhinosinusitis resulting from an IgE-mediated hypersensitivity reaction. The diagnosis of AFS can be established by demonstrating type I hypersensitivity, presence of fungus in mucus, eosinophilic mucin, nasal polyposis, and characteristic CT scans. Although AFS is not unusual and its incidence may be increasing, few cases have been reported in Korea. Here, we report the first case of typical AFS in which Curvularia species was isolated by culture.

Sinusitis alérgica micótica / Allergic fungal sinusitis

Desde que la sinusitis alérgica micótica fue descripta inicialmente por Millar y cols. en 1981, se ha tratado de definir y explicar esta enfermedad. Ha sido comparada con la aspergilosis broncopulmonar alérgica; sin embargo, no puede ser categorizada tan fácilmente. De acuerdo con la literatura que existe hasta el momento, hay cinco criterios mayores y seis características asociadas, o criterios menores, para definir esta enfermedad. En realidad, la mayoría de los pacientes pueden presentar los cinco criterios mayores o las otras características asociadas durante los años de evolución. No sólo es difícil el diagnóstico de esta patología, sino también es complicado su manejo. Para un control efectivo de la enfermedad y evitar las recurrencias, el tratamiento incluye cirugía endoscópica de los senos y terapia médica a largo plazo; esto es: corticoides por vía oral y nasal, inmunoterapia con alergenos y antifúngicos.(AU)

Since allergic fungal sinusitis was initially described by Millar et al, in 1981, many have tried to define and explain the disorder. It has been labeled as the sinonasal equivalent of allergic bronchopulmonary aspergillosis; however, allergic fungal sinusitis cannot be categorized so easily. According to current literature, there are five major criteria and six associated characteristics, or minor criteria, of patients with allergic fungal sinusitis. This disease is not only difficult to diagnose, but one of the most complicated conditions rhinologists must manage. Endoscopic sinus surgery must be used in conjunction with long-term medical therapy, i.e., oral and nasal corticosteroids, allergen immunotherapy and antifungal therapy to effectively control the problem.(AU)

Clinical Characteristics of Allergic Fungal Sinusitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The diagnosis of the allergic fungal sinusitis (AFS) can be established by demonstrating type I hypersensitivity, nasal polyposis, characteristic CT scans, eosinophilic mucin and a positive fungal stain of mucus. There are certain conditions may also present clinically just like AFS, but in these cases, neither the presence of fungus nor the allergy can be documented. Some authors termed this condition as "AFS-like syndrome". Whether the AFS-like syndrome is a spectrum of AFS or different disease entity remains unclear. The objective of this study was to analyze the clinical features of allergic fungal sinusitis and to compare clinical features of AFS with those of AFS-like syndrome. SUBJECTS AND METHOD: Five patients with AFS and six patients with AFS-like syndromes were analyzed in terms of clinical manifestations, presence of associated diseases, radiologic findings, allergic test, treatment, and treatment outcome. RESULTS: Patients with AFS were younger than those with AFS-like syndrome. All patients of AFS group had histories of allergic disease. Eighty percent of AFS group patients had unilateral lesions, while 18 percent of AFS-like syndrome patients had unilateral lesions. Serum total IgE was more elevated in AFS group. On CT scan, characteristic findings such as heterogeneous soft tissue density, erosion of bony septa, and expansion of sinus wall were more frequently found in AFS group. There was no difference in treatment outcome between two groups. CONCLUSION: These results may suggest that AFS-like syndrome is a different disease entity from AFS.

Allergic Fungal Rhinosinusitis

Allergic fungal sinusitis (AFS) is a benign, noninvasive variety of fungal sinusitis. AFS was first reported in 1983. The first case of AFS was associated with Aspergillus. However, it is now clear that most cases of AFS are caused by non-Aspergillus species. AFS is more frequently encountered at present due to changes in fungal taxonomy and improved culture techniques. There is a geographical difference in the incidence of AFS. It accounts for 5% to 10% of all cases of chronic rhinosinusitis requiring surgical intervention in the United States and has become a subject of increasing interest to otolaryngologists and related specialists. However, only 2 cases of AFS have been reported in Korea. It is extremely important to recognize AFS and to differentiate it from chronic bacterial sinusitis or other types of fungal sinusitis because the treatment and prognosis of these disorders are significantly different. The prognosis and optimum treatment of AFS are still unknown. This article reviews the current understanding of epidemiology, pathology, diagnosis and reatment of AFS.

A Case of Allergic Fungal Sinusitis / 대한이비인후과학회지

Since the initial description of allergic fungal sinusitis by Millar et al. in 1981, reported cases have been increasing. However, one case of allergic fungal sinusitis has been reported in Korea. The diagnosis can be established by demonstrating type I hypersensitivity reaction, nasal polyposis, characteristic CT scan, eosinophilic mucus without evidence of fungal invasion into sinus tissue, and a positive fungal stain or culture of sinus contents. The authors present a case which met the diagnostic criteria of allergic fungal sinusitis. This patient had nasal polyp and showed elevated level of total IgE, peripheral eosinophilia, positive MAST and strongly positive immediate skin reactivity to fungal antigens. On histologic examination, typical allergic mucin containing sheets of eosinophils, Charcot-Leyden crystals was found. Fungal hyphae were also found in the mucin content.

A Case of Allergic Fungal Sinusitis / 대한이비인후과학회지

Allergic fungal sinusitis (AFS) has been clinicopathologically defined as a noninvasive form of fungal infection. AFS was first reported in 1983. The first case of AFS was associated with Aspergillus, but recently other fungal organisms have been implicated. AFS should be suspected in any atopic patients with refractory nasal polyps. Sinus computed tomograms and magnetic resonance imaging findings can be quite distinctive, but definite diagnosis requires histopathologic examination which shows characteristic allergic mucin. Current recommendations for therapy include conservative but complete exenteration of all allergic mucin. Adjunctive systemic steroids are often helpful. The authors present a case of allergic fungal sinusitis for the first time in Korea. The patient had nasal polyp and showed hypersitivity to fungus in RAST, elevation of total IgE, peripheral eosinophilia. On histopathologic examination, typical allergic mucin including Charcot-Leyden crystals, eosinophils and fungal hyphae were found.

Allergic Fungal Sinusitis: A Report of Two Cases

Allergic fungal sinusitis (AFS) is a benign, noninvasive form of fungal sinusitis. Histologically, AFS is characterized by allergic mucin, which consists of eosinophilic mucinous material with occasional laminar deposits of eosinophils. A diagnosis of AFS can be made when there is a demonstration of characteristic allergic mucin and an appearance of fungal hypae scattered within the mucin with no evidence of tissue invasion, or when fungi cultures yield positive results. Until now, no cases of AFS have been reported in Korea, though there have been many cases of mycetomas and a few cases of invasive fungal sinusitis. We present the first two cases of AFS in Korea. The patients demonstrated characteristic allergic mucin, fungal hypae scattered within the mucin, and no evidence of tissue invasion on histopathology. Nasal polyps, involvement of the unilateral sinuses, peripheral eosinophilia, an elevated total IgE, and hyperattenuated masses observed in the CT supported the diagnosis of AFS. The patients recovered and did not display recurrence after surgery and treatment with topical steroids and saline irrigation.