Disseminated Cutaneous Sporotrichosis with Fungal Sinusitis As An Initial Presentation of Underlying Myeloproliferative Neoplasm

Summary@#Sporotrichosis is a rare and chronic granulomatous subcutaneous mycotic infection caused by a dimorphic fungus, Sporothrix schenckii. We describe a patient with disseminated cutaneous sporotrichosis who was later diagnosed with myeloproliferative neoplasm and discuss the challenges and importance in diagnosing this rare condition.

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)

A Study Of Paranasal Sinus Complications In Post Covid Patients At A Tertiary Care Centre

Background:Paranasal sinus complications in patients recovering from COVID 19 ison the rise. This study is to evaluate the clinically suspected cases of Post Covid Sinusitis patients.Material And Methods:Total 200 cases of Post Covid Sinusitis patients were included in this study. The demographic profile, clinical and radiological presentation, underlying immunocompromised status, laboratory results and treatment outcome of the patients was analysed.Result:Post Covid Sinusitis was observed mainly in the fifth and sixth decade of life with a male predominance. Most common associated disease was diabetes mellitus (77%). Laboratory analysis revealed infection with Mucor and Aspergillus species most commonly. Sino-nasal, orbital, cerebral, palatine and skin involvement found in 100%, 40%, 12.5%,37% and 2.5% of patients, respectively. Symptoms and signs are headache (62.5%), cheek swelling(40%),and decreased vision(26.5%). All patients were treated by surgical debridement, antibiotics and antifungal medications. Overall survival rate was 87.5%.Conclusion:Clinical suspicion and early diagnosis in post covid patients followed by surgical debridement of diseased tissue, antifungal and antibiotic medications are crucial for better prognosis and improved survival rates.

Sinonasal Mucormycosis in a Diabetic - Case Report

Background : Mucormycosis is one of the rapidly progressing and lethal form of fungal infection which involves the nose and paranasal sinuses of the head and the neck regions. It manifests as rhinocerebral, sinonasal, pulmonary, gastrointestinal, cutaneous or disseminated form. The underlying conditions can influence clinical presentation and often delay diagnosis, with resultant poor outcomes. Objective: To present and discuss the case of a diabetic patient with sinonasal mucormycosis presented with facial pain and discolouration of right side of nose and face due to mucormycosis. Case report: A 23 years old female patient presented to emergency with uncontrolled blood sugars, pain and swelling over right side of face and blackish discolouration of right side of nose. On examination, there was bluish black discolouration of skin over right side of dorsum of nose and right ala of nose and right nasal vestibule. Sinus CT scan showed features suggestive of fungal sinusitis. Mucormycosis was suspected, confirmed with biopsy and surgical debridement and medial maxillectomy done. Intravenous amphotericin B was administered for 21 days. The patient was followed up regularly, the disease appearing to be resolved. Conclusion: Mucormycosis is a rapidly progressive fatal infection mostly reported in immune-compromised individuals. Emergency multidisciplinary treatment for control of blood sugars, surgical debridement and effective antifungal medications gives better clinical outcome.

A Case of Fungal Sinusitis Successfully Treated with Shin'iseihaito / 日本東洋医学雑誌

The treatment for fungal sinusitis is general irrigation of the sinus or surgery. We report a case in which shin'iseihaito was used to treat fungal sinusitis. The patient was a 57-year-old man. On May 17, he underwent wisdom tooth extraction at the dentistry department of a hospital. Fungal sinusitis of the right maxilla was suspected on preoperative CT of paranasal sinuses. On June 19, he was introduced to the department of otolaryngology in the same hospital. The ostium of the right maxilla was widely open and there were fungal balls in the sinus. Saline irrigation was performed as an outpatient procedure and at home. On October 19, he was introduced to my clinic as he lives nearby. We prescribed him shin'iseihaito. On November 11, fungal balls were discharged when he was performing saline irrigation at home. The pathological diagnosis was Aspergillus. Although there is no previous report of shin'iseihaito for fungal sinusitis, it may be a useful treatment.

A Study on Orbital Cellulitis Due to Acute Sinusitis: A Multidisciplinary Approach

Introduction: Orbital infection has spread beyond the orbital septum leads to orbital cellulitis. The distinctive features of orbitalcellulitis are proptosis and limitation of ocular movements. Additional useful signs are chemosis of bulbar conjunctiva, reducedvisual acuity, afferent pupillary defect, and toxic systemic symptoms. Prompt diagnosis and treatment of orbital cellulitis is vitalas it is associated with serious complications such as cavernous venous thrombosis, visual loss, meningitis, brain abscess,and sepsis.Aims and Objectives: The purpose of this study is to evaluate clinical presentation, treatment outcomes, and post-surgicalcomplications of diagnosed case of orbital cellulitis.Materials and Methods: This is a cross-sectional study of patients with orbital cellulitis as a complication of acute sinusitis. Allthe patients were subjected to thorough clinical examination, ophthalmic and radiological evaluation. Computed tomographyof paranasal sinuses done. All the patients in this study received appropriate medical and surgical management and follow-upevaluation done at the 1st month and 3 months.Results: Orbital cellulitis due to fungal sinusitis is prevalent among uncontrolled type 2 diabetes mellitus patients in our study.Surgical management such as endoscopic sinus surgery with intravenous antibiotic therapy found to be more effective thanconservative management alone.Conclusion: Strict diabetic control, appropriate surgical and medical management, and a vigilant follow up resulted to a better outcome.

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.

Bola fúngica de cavidades paranasales: serie de casos / Fungus ball of the paranasal sinuses: case series

RESUMEN Introducción La bola fúngica (BF) es una sinusitis fúngica no invasiva, con acumulación extramucosa de conglomerados densos de hifas de hongos en cavidades paranasales (CPN), afectando generalmente a mujeres inmunocompetentes. Objetivo Describir la presentación cínica, diagnóstico y tratamiento de una serie de pacientes con diagnóstico de BF de CPN. Material y método Estudio descriptivo retrospectivo de pacientes con diagnóstico histopatológico de BF sometidos a cirugía endoscópica nasal (CEN) en nuestra institución entre 2010 y 2016. Resultados Se incluyeron 20 pacientes (15 mujeres, 5 hombres), con edad promedio al diagnóstico de 64 años (35-86 años), la mayoría inmunocompetente (85%). El síntoma más frecuente fue dolor facial (8/20). Todos los pacientes fueron estudiados con tomografia computarizada (TC) de CPN, presentando calcificaciones en 70%. La ubicación más frecuente fue el seno maxilar (12/20) y luego esfenoidal (6/20). Se realizó CEN en todos los pacientes, combinándolo con Caldwell Luc en 3 de ellos. Los cultivos intraoperatorios resultaron negativos en el 75% de los pacientes. Conclusión La BF tiene presentación cínica inespecifica. Se sospecha en base a hallazgos imagenológicos en la TC de CPN y se confirma histopatológicamente, dado el bajo rendimiento de los cultivos. La CEN es la herramienta diagnóstico-terapéutica de elección, con baja tasa de recidiva local.

ABSTRACT Introduction A fungus ball (FB) is a non-invasive fungal sinusitis, consisting of extramucosal accumulation of dense fungal hyphae conglomerates, located in paranasal sinuses. It generally affects immunocompetent women. Aim To describe the clinical presentation, diagnosis and treatment in a series of patients diagnosed with FB of paranasal sinuses. Material and method Retrospective descriptive study regarding all patients with a histopathologic diagnosis of FB, who underwent endoscopic sinus surgery (ESS) in our institution between 2010 and 2016. Results Twenty patients (15 women, 5 men) were included, with a mean age at diagnosis of 64 years (35-86 years). Most were immunocompetent (85%). Facial pain was the most frequent symptom (8/20). All patients were studied with a sinus CT, finding paranasal calcifications in 70%. It predominantly involved the maxillary (12/20), and sphenoid sinus (6/20). All patients were treated with ESS, with a combined Caldwell Luc approach in only 3 of them. Intraoperative cultures were negative in 75% of patients. Conclusions Sinus FB has a non-specific clinical presentation. CT findings help suspect it, and it is confirmed with a histopathological study, given the poor efficiency of cultures. ESS is the diagnostic-therapeutic procedure of choice, with a low local recurrence rate.

A Case of Periorbital Necrotizing Fasciitis Occurred in Patient with Fungal Sinusitis / 대한이비인후과학회지

Orbital complications due to sinusitis usually occur in children and spread from the ethmoid or frontal sinusitis. Periorbital necrotizing fasciitis, which is an aggressive infection characterized by extensive necrosis and gas formation in the fascia and subcutaneous tissue, is uncommon as an orbital complication due to sinusitis. Because most of orbital complications of the fungal sinusitis occur from invasive fungal infection in immunocompromised patients, orbital complications due to non-invasive maxillary fungal ball in healthy patients are extremely rare, especially if the complication is periorbital necrotizing fasciitis. We report a case of periorbital necrotizing fasciitis that occurred in a healthy 44-year-old male patient with non-invasive fungal sinusitis, which was treated with a combination of intravenous antibiotics and endoscopic sinus surgery and ophthalmologic surgical treatment.

Chronic invasive fungal rhinosinusitis by Paecilomyces variotii: A rare case report.

Fungal infection of the paranasal sinuses is an increasingly recognised entity, both in normal and immunocompromised individuals. The recent increase in mycotic nasal and paranasal infections is due to both improved diagnostic research and an increase in the conditions that favour fungal infection. Aspergillus, Candida, and Mucor species are the most common causative agents of fungal sinusitis, but infection with lesser known species have been reported across the world infrequently. This article reviews and presents a case report of chronic fungal sinusitis in an immunocompetent adult male infected with Paecilomyces variotii which is opportunistic soil saprophyte, uncommon to humans.

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.

Clinico-Radiological Manifestations of Invasive and Non-Invasive Fungal Infections in Sinuses and Respiratory Tract.

Introduction : Fungal sinusitis was once considered a rare disorder but is now reported with increasing frequency throughout the world. Fungal chest infection is relatively considered common. 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 made the invasive group, whereas non-invasive fungal infection is composed of allergic fungal sinusitis and fungus ball (fungal mycetoma). Objective : The five subtypes of sinusitis described above are distinct entities with different clinical and radiologic features. The treatment strategies for the subtypes are also different, as are their prognosis. We aim to clearly delineate the radiologic features of culturally proven fungal cases so as to direct the clinician towards expeditious diagnosis and necessary treatment. Methodology : 40 culturally positive patients with the spectrums of different manifestations were studied and recorded. They were followed up for one month. Conclusion : An understanding of the different types of fungal sinusitis and knowledge of their particular radiologic features allowed 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 avoided a protracted or fatal outcome.

A clinical research of endoscopic sinus surgery to treat noninvasive fungal sinusitis / 安徽医科大学学报

Evaluation methods of chronic sinusitis ( Visual Analogue Score and Lund-Kennedy Score) were recom-mended by the 2009 Chinese Medical Association otolaryngology head and neck surgery to nasal Science Group,and retrospective analysis of the functional endoscopic sinus surgery for noninvasive fungal sinusitis treatment effect of 143 patients. VAS of preoperative was 5.8±1.0,postoperative score was 3.9±1.0, 2.4±0.9 after 3 months,6 months, respectively (P<0.01). Lund-Kennedy Score of preoperative was 7.7±2.1, postoperative score was 3.7±1.9, 1.6±1.4 after 3 months,6 months respectively (P<0.01).

New Treatment for Isolated Invasive Aspergillosis of Sphenoid Sinus in Immunocompetent Subjects: Sphenoid Nasalization Combined with Voriconazole / 대한이비인후과학회지

Isolated invasive fungal sinusitis of sphenoid sinus in a healthy immunocompetent person is extremely rare. Classical treatment of invasive fungal sinusitis is wide sphenoidotomy and surgical debridement combined with antifungal agents, mostly amphotericin B. We describe a case of a 72-year-old immunocompetent woman who presented with deep-seated orbital pain and was diagnosed as isolated invasive aspergillosis in sphenoid sinus invading orbital apex and cavernous sinus. This case was treated successfully with a new combination treatment of sphenoid nasalization and voriconazole, a new antifungal agent. There was no evidence of postoperative recurrence and side effects during the usage of voriconazole.

A Case of Optic Neuropathy Caused by Fungal Ball in an Onodi Cell

PURPOSE: To report a rare case of optic neuropathy caused by a fungal ball in an Onodi cell. CASE SUMMARY: A 63-year-old female was referred to our clinic with relapsed visual loss and ocular pain in the right eye. She had been diagnosed as optic neuritis 14 days before and given pulse steroid therapy. She recovered to normal but relapsed 7 days before. In medical referral there was no suspected multiple sclerosis but only a few inflammation in the paranasal sinuses. On our initial examination, best corrected visual acuity was counting finger at 10 cm in the right eye, and 1.0 in the left eye, along with relative afferent pupillary defect in the right eye. The fundoscopic examinations disclosed disc swelling; nearly total visual field defect was observed on visual field examination and visual evoked potential test revealed decreased amplitude at P100 wave in the right eye. Clinical impression was relapsed optic neuritis. After the administration of pulse steroid therapy, her disc swelling was decreased and visual acuity was recovered to 0.6, however, visual acuity was exacerbated to 0.4 in 2 weeks. We checked outside brain magnetic resonance imaging (MRI) and the result showed optic neuropathy caused by a fungal ball in an Onodi cell. The patient was referred to otorhinolaryngologist and fungal ball was removed by endoscopic sinus surgery. 3 weeks after surgery the patient's visual acuity was 0.9, no disc swelling was found and visual evoked potential was recovered to normal. CONCLUSIONS: An Onodi cell lesion should be considered in the differential diagnosis of optic neuritis, identified by imaging studies and promptly removed by surgery for visual recovery.

Trichosporon inkin, an unusual agent of fungal sinusitis: A report from south India.

The aetiology of fungal sinusitis is diverse and changing. Aspergillus species has been the most common cause for fungal sinusitis, especially in dry and hot regions like India. Trichosporon species as a cause for fungal sinusitis has been very rarely reported the world over. Here, we report a rare case of allergic fungal sinusitis caused by Trichosporon inkin in a 28-year-old immunocompetent woman. Bilateral nasal obstruction, nasal discharge and loss of smell were her presenting complaints. Diagnostic nasal endoscopy showed bilateral multiple polyps. Functional endoscopic sinus surgery was performed and many polyps were removed. Based on mycological and histopathological studies, the pathogen was identified as T. inkin.

Rapidly Progressive Rhino-orbito-cerebral Mucormycosis Complicated with Unilateral Internal Carotid Artery Occlusion: A Case Report / 신경중재치료의학

Rhinocerebral mucormycosis is an acute fulminant opportunistic fungal infection usually seen in diabetic or immunocompromised patients. The fungi that cause mucormycosis inoculate the nasal mucosa and may spread to the paranasal sinuses, orbit, and brain. Our patient initially presented with mild ethmoid sinusitis. At that time, brain MRI and contrast-enhanced MR angiography were grossly normal. However, aggravation of sinusitis with extension to the right orbit and anterior cranial fossa rapidly developed within two months. Moreover, an occlusion of the right internal carotid artery was combined. We report a case of a pathologically-proven rhino-orbital-cerebral mucormycosis with serial follow-up imaging for over one year.

Schizophyllum commune sinusitis in an immunocompetent host.

Schizophyllum commune is widely distributed in the nature, but it rarely causes human infection. We have isolated this mould in a 46-year-old immunocompetent, non-diabetic patient with chronic sinusitis, previously treated with multiple antibiotics and topical steroid nasal drops with no response. Materials obtained from the nasal sinus during the endoscopic surgery, on KOH mount and histopathological study revealed broad septed hyaline hyphae. Growth on the Sabouraud's dextrose agar and potato dextrose agar produced white moulds with microscopic and macroscopic characters of S. commune. Till date there are few reports of S. commune sinusitis in immunocompetent individuals Worldwide. This is the first reported case in India to the best of our knowledge.

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.