Mucormicosis rinosinusal por mucor hiemalis en una paciente con leucemia mieloide aguda / Rhinosinusal mucormycosis by mucor hiemalis in a patient with acute myeloid leukemia

Se reporta un caso clínico de una paciente femenina de 41 años, con antecedentes de leucemia mieloide aguda (LMA) en remisión. Estudiada por hematología, se confirmó recaída de LMA M4. Se inició quimioterapia. La paciente evolucionó con pancitopenia severa. Presentó dos episodios de neutropenia febril, el primero fue asociado a un absceso glúteo que se trató con antibacterianos, y el segundo a compromiso rinosinusal y úlcera necrótica de punta nasal, columela, tabique, cornete inferior izquierdo y paladar duro. Debido a la clínica e imá- genes radiológicas, se sospechó mucormicosis, por lo que se realizó cirugía con debridación extensa y se inició tratamiento antimicótico con anfotericina B desoxicolato. El cultivo de tejido informó abundante desarrollo de Mucor hiemalis. Se mantuvo pancitopénica durante aproximadamente un mes, siendo diariamente evaluada por un equipo multidisciplinario. Se hicieron varios aseos quirúrgicos, en el último se encontró tejido vital. La paciente completó diez días con anfotericina B desoxicolato y posteriormente se hizo traslape a posaconazol oral. Se realizó mielograma de control que evidenció remisión completa de recaída de LMA. Se dio de alta a su domicilio al día 40 de hospitalización, con hemograma adecuado y tratamiento oral con posaconazol para completar 6 semanas en total.

We report a case of a 41-years-old female patient with a history of acute myeloid leukemia (AML) in remission. Hematology studies confirmed relapse of AML M4. Chemotherapy was started. The patient developed severe pancytopenia. She presented two episodes of febrile neutropenia, the first one was associated with a gluteal abscess that was treated with antibacterials, and the second to rhinosinusal involvement and necrotic ulcer of nasal tip, columella, septum, left inferior turbinate and hard palate. Due to clinical and radiological imaging, mucormycosis was suspected, so surgery was performed with extensive debridement and antifungal treatment with amphotericin B deoxicholate was initiated. Tissue culture reported abundant development of Mucor hiemalis. She remained pancytopenic for approximately one month, being evaluated daily by a multidisciplinary team. Several surgical were made, finding vital tissue in the last perform. The patient completed ten days with amphotericin B deoxicholate and later was overlapped to oral posaconazole. A control myelogram was performed, showing complete remission of AML. She was discharged to her home at day 40 of hospitalization, with adequate blood count and oral treatment with posaconazole to complete 6 weeks in total.

As alterações nasofibroscópicas e tomográficas de seios paranasais são preditoras de gravidade em pacientes com fibrose cística / Nasal endoscopic and CT scan alterations of the paranasal sinuses as predictors of severity in patients with cystic fibrosis

A fibrose cística (FC) resulta de mutação no gene regulador da condutância transmembrana, responsável pelo controle dos processos secretores. As vias aéreas superiores (VAS) geralmente são comprometidas na forma de pansinusite crônica. OBJETIVO: Avaliar as alterações das VAS nos pacientes com FC e determinar a correlação entre os achados tomográficos e endoscópicos nasossinusais e a gravidade da doença. MÉTODO: Estudo transversal, prospectivo com 20 pacientes maiores de 5 anos com diagnóstico de FC avaliando escore de Shwachman-Kulczycki (S-K), tomografia de seios paranasais (TC) (escore de Lund-Mackay) e videonasofibroscopia (escore de Meltzer). RESULTADOS: Alterações tomográficas foram observadas em 94% dos casos. Alterações endoscópicas nas VAS foram encontradas em dez pacientes. Pólipo nasal ocorreu em três pacientes (15%). Observou-se correlação entre a intensidade das alterações da TC e o escore S-K (p = 0,0097) e entre os achados endoscópicos e o escore S-K (p = 0,0318). Observou-se relação positiva entre a presença de colonização crônica e os achados endoscópicos (p = 0,0325), o que não foi observado com os achados tomográficos (p = 0,2941). CONCLUSÃO: Há correlação inversa entre o escore clínico de S-K e os achados de TC e nasofibroscopia. Portanto, os pacientes clinicamente mais graves de acordo com o escore de S-K apresentam maior comprometimento de VAS.

Cystic Fibrosis (CF) results from mutation in the transmembrane conductance regulator gene, responsible for controlling secretory processes. The upper airways (UA) are usually involved in the form of chronic pansinusitis. OBJECTIVE: To evaluate UA changes in patients with CF and to establish the correlations between sinonasal CT and endoscopic endonasal findings and disease severity. METHOD: Cross-sectional and prospective study with 20 patients older than 5 years with CF, assessing the Shwachman-Kulczycki (S-K) score, paranasal sinus tomography (CT) (Lund-Mackay score) and nasal endoscopy (Meltzer score). RESULTS: CT scan alterations were observed in 94% of cases. Endoscopic alterations findings in the upper airways were found in 10 patients. Nasal polyps were found in 3 patients (15%). There was a correlation between the intensity of changes on the CT and S-K score (p = 0.0097), and between endoscopic findings and S-K score (p = 0.0318). There was a positive correlation between the presence of chronic colonization and endoscopic findings (p = 0.0325), which was not observed on the CT (p = 0.2941). CONCLUSION: There is an inverse correlation between the S-K clinical score and nasal endoscopy and CT findings. Therefore, patients who are clinically more severe according to the S-K score have greater UA involvement.

Bola fúngica dos seios paranasais: Relato de dois casos e revisão de literatura / Fungus ball of the paranasal sinuses: Report of two cases and literature review

Introdução: Bola fúngica dos seios paranasais é uma infecção não invasiva que se caracteriza por sua cronicidade, sendo a maioria relacionada com tratamento endodôntico prévio. Acomete principalmente o seio maxilar, embora todos os seios possam ser envolvidos. O principal agente etiológico é o Aspergillus spp. A tomografia computadorizada, devido às apresentações radiológicas características, sugere o diagnóstico que é realizado definitivamente através de análises histopatológicas. O tratamento padrão-ouro é a cirurgia sinusal endoscópica com antrostomia meatal média. Objetivo: Relatar dois casos de bola fúngica dos seios paranasais e ressaltar aspectos importantes desta patologia. Relato dos Casos: Caso 1) Paciente do sexo feminino, 78 anos, apresentou-se com queixas de dor facial há 6 meses e história prévia de tratamento endodôntico. Ao exame físico constatou-se a presença de secreção purulenta em meato médio esquerdo. O Raio X apresentou velamento completo do seio maxilar esquerdo, enquanto a tomografia computadorizada mostrou lesão calcificada neste local. Realizou-se sinusotomia que evoluiu bem. Caso 2) Paciente do sexo feminino, 70 anos, procurou atendimento por história de sinusites de repetição. Ao exame físico não se percebeu nenhuma particularidade. A tomografia computadorizada, assim como a ressonância magnética, detectou espessamento da parede mucosa do seio maxilar esquerdo, além de uma massa calcificada. Realizou-se a mesma sequência de tratamento e a paciente também evoluiu bem. Considerações finais: A infecção fúngica deve ser considerada nos pacientes que se apresentam com sinusite crônica, que não respondem ao uso de antibióticos e que possuem história de manipulação endodôntica...

Introduction: Fungal ball of the sinuses is a not invasive infection that if characterizes for its chronicity, being the majority related with previous endodontic treatment. Affect mainly the breasts to maxillary; even so all the breasts can be involved. The main etiological agent is the Aspergillus spp. The computed tomography, had to characteristic the radiological presentations, suggests the diagnosis that is carried through definitively through histopathological analyses. The treatment standard-gold is the sinus surgery with average meatal antrostomy. Objective: Reporting two cases of fungal ball of the sinuses and to stand out important aspects of this pathology. Story of the Cases: Case 1) Patient of the feminine sex, 78 years old, presented itself with complaints of face pain has 6 months and previous history of endodontic treatment. To the physical examination it was evidenced purulent secretion presence in left average meatus. Ray X presented complete veiling of the breasts to maxillary left, while the computed tomography showed injury calcified in this place. Sinusotomy was become fulfilled that evolved well. Case 2) Patient of the feminine sex, 70 years old, looked attendance for history of sinusitis of repetition. To the physical examination no particularity was not perceived. The computed tomography, as well as the magnetic resonance, detected thickening of the mucous wall of the breasts to maxillary left, beyond a calcified mass. It was become fulfilled same sequence of treatment and the patient also evolved well. Final Considerations: The fungal infection must be considered in the patients who if present with chronic sinusitis, that they do not answer to the antibiotic use and that they possess history of endodontic manipulation...

[ relationship between the colonization of helicobacter pylori in the mucosa of the paranasal sinuses and chronic sinusitis]

Chronic rhinosinusitis is one of the most common chronic diseases which can adversely affect patients' quality of life with a considerable economical burden. Bacteriology of chronic rhino sinusitis is not well defined. Recently, Helicobacter pylori gained a considerable concern in respect to its probable association with upper respiratory tract diseases. This study aimed to evaluate the relationship between H. pylori colonization in sinonasal mucosa and chronic rhinosinusitis. This case-control study was conducted in Ayatollah Taleghani General Hospital - Tehran in 2007-2008. All patients with chronic rhinosinusitis who failed to respond to the medical therapy [32 patients], enrolled as case group and samples were taken from involved sinonasal mucosa during endoscopic surgery. Patients with nasal septum deviation [65 cases] recruited as control group and samples were evaluated for Helicobacter colonization by using polymerase chain reaction [PCR] technique and results in two groups were compared. 97 patients [61% male and 39% female] were studied ranging in age from 12 to 53 years, with an average of 29.6 years. Out of 32 patients in the case group, 56% were male and 44% female, aging from 12 to 53 years [averagely 32.16 years]. 65 cases of the control group [63% male and 37% female] were 16-50 years old with an average age of 28.34 years. After the evaluation of samples from 97 patients in both study groups, 16 patients out of 32 in chronic rhino sinusitis group [50%] and 7 out of 65 patients in control group [10.7%] had positive results for helicobacter colonization in their sinonasal and bulla ethmoidalis mucosa which was statistically significant [p<0.001, and Odds Ratio= 8.28, 95% CI= 2.9-23.59]. There was no statistically significant relation between H. pylori colonization and site of involved sinus or typical symptoms of gastro-esophageal reflux. According to the results of current study, there was a significantly higher rate of Helicobacter pylon colonization in chronic rhinosinusitis patients compared to the control group. This finding suggests that Helicobacter pylori may play an etiologic role in pathogenesis of chronic rhinosinusitis

Bacteriología de las exacerbaciones agudas de rinisonusitis crónica en pacientes operados por cirugía endoscópica de cavidades paranasales / Bacteriology of chronic rhinosinusitis in patients that had paranasal sinuses endoscopio surgery

Introducción: La rinosinusitis crónica (RSC) es un cuadro inflamatorio en el que las bacterias juegan un rol importante. Las exacerbaciones agudas de rinosinusitis crónica (EARSC) en pacientes posoperados no son infrecuentes. Sin embargo, su manejo es complejo debido a la aparición de nuevos agentes y el aumento de la resistencia a antibióticos. Objetivo: Desarrollar una técnica de toma de muestra en cavidades paranasales, que permita caracterizar a los agentes involucrados en EARSC en pacientes posoperados. Material y método: Se recluta ron 32 pacientes posoperados. Se realizó aspirado de seno maxilar bajo visión endoscópica. Las muestras fueron cultivadas para aerobios, anaerobios y hongos. Resultados: Se enviaron 50 muestras a cultivo, en 46 de ellas se aislaron gérmenes (92%), de los cuales 44 fueron aerobios. En 7 de las muestras se aislaron anaerobios, y en 2 se obtuvo cultivo positivo para hongos. La resistencia a betalactámicos fue de 48,2%, observándose 36% de resistencia a lo menos a dos familias de antibióticos. Discusión y conclusiones: Nuestro estudio es el primero a nivel nacional en caracterizar a los agentes involucrados en EARSC en pacientes poscirugía endoscópica nasal. Los resultados obtenidos, posicionan a los cultivos endoscópicos como una excelente herramienta clínica para estudiar las EARSC.

Introduction: Chronic rhinosinusitis (CRS) is an inflammatory condition where bacteria play an important role. Acute exacerbations of chronic sinusitis (AECS) in patients who underwent endoscopic sinus surgery (EES) are not infrequent. Treatment of these exacerbations is complex due to the emergence of new agents and to an increase in bacterial resistance. Therefore, it is important to develop methods to culture and identify these agents and their antimicrobial resistance and sensibilities. Aim: To develop a technique for recovery of pathogens in the paranasal sinuses of patients with AECS after EES. Material and Method: 32 patients that had undergone EES were recruited. Aspiration of the maxillary sinus under direct endoscopic vision was performed. Samples obtained were sent for aerobic, anaerobia and fungal cultures. Results: Of the 50 samples collected, 46 were positive. Of these, 44 cultured aerobes, 7 cultured anaerobes, and 2 cultured fungi. The resistance to betalactamic antibiotics was 48.2% with at least 36% resistance to two different types of antibiotics. Conclusion: This is the first report in Chile of the microorganisms involved in AECS after EES. The results suggest that the sampling method described here is a useful tool for the study of patients with AECS.

Invasive aspergillosis of paranasal sinuses: findings from the Sudan

The Sudan is endemic for Aspergillus species, especially Aspergillus flavus. They commonly invade the paranasal sinuses, but massive invasion of the brain in immunocompetent patients is rare. To describe the clinical presentation and MRI findings in immunocompetent patients with massive paranasal aspergillosis with extensive invasion of the brain. Four patients, who are negative for HIV and other immunocompromizing disorders were studied in this article. Two females 55 and 25 year old, 2 males 29 and 62 year old were described. All cases showed extensive invasion of the paranasal sinuses and the adjacent structures. Invasive paranasal Aspergillosis can affect immunocompetent patients and the commonest organism is Aspergillus flavus

Paranasal sinus mycosis in suspected fungal sinusitis

Fungal infections of the paranasal sinuses in the immunocompetent patients are being recognized with increasing frequency. Infections are assigned in invasive and noninvasive forms. Materials and methods: In a retrospective study, a total 39 patients with suspected fungal sinusitis were studied for causative fungal.agents between 1994 and 2001 Dinagnosis was confirmed by demonstration of fungi in direct preparations and culture techniques. Samples were biopsy specimens taken from the sinuses or exudates from deep sinus tracts. Paranasal sinuses mycoses were proven in 18 patients, including 12 men and 6 women, their age ranging from 17-58 years. The most frequently isolated organisms were Aspergillus spp. and Candida spp. Paranasal sinuses infections by Cladosporium trichoides [bantianum] and Pseudallescheria boydii are reported for the first time in Iran from Pasteur Institute, Conclusion In our series. Aspergillus flavus has been isolated more frequently than other agents. Keywords: Fungal infecrtion, Paranasal sinuses infection, Sinuses mycoses

Rinosinusitis infantil / Infantile rhinosinusitis

Los niños tienen en promedio entre 6 a 8 infecciones respiratorias altas por año, de las cuales entre el 5 por ciento y el 10 por ciento devienen en rinosinusitis bacterianas. Debido a que este proceso está siempre asociado a una rinitis, en la actualidad se tiende a emplear el término rinosinusitis más que el de sinusitis [1,2]. En este artículo se entiende el término rinosinusitis como una infección bacteriana, sin considerar el concepto más histopatológico de inflamación de un seno perinasal. A pesar de su frecuencia, no es fácil para el médico diferenciar una infección respiratoria simple de una complicada con rinosinusitis y lo es más diagnosticar una rinosinusitis crónica con indicación de cirugía.

Zygomycosis due to Conidiobolus coronatus in west Bengal.

Zygomycosis of upper respiratory tract, caused by Conidiobolus coronatus, in eight Bengalee males and one female is described. The clinical syndrome of the cases included initial coryza, epistaxis, intranasal tumor, nasal obstruction, broadening of bridge of nose with swelling of paranasal sinuses, dorsum of nose, alae nasi, cheek and glabella in all or majority of the cases. In addition upper lip or both lips and pharynx were involved in some cases. Swellings were fixed to the skin in seven cases and to the deeper tissues in five cases. The fungus was demonstrated by direct microscopy in the nasal mucosa, and was isolated in culture. The isolates produced conidia, replicative conidia and villose conidia but not multiplicative conidia. The disease was cured with KI and/or ketoconazole/fluconazole. The cases described here constitute the first report on zygomycosis due to C. coronatus from North-eastern India.

Mucormicosis rinocerebral: caso clínico / Rhinocerebral mucormycosis: clinical case

La mucormicosis es una enfermedad poco frecuente, causada por hongos del orden de los mucorales. Suele presentarse en pacientes con algún grado de inmunodepresión. La forma rinocerebral afecta principalmente a pacientes con cetoacidosis diabética. El cuadro clínico corresponde al de una sinusitis invasiva, con un curso generalmente fatal y el tratamiento es médico-quirúrgico. Se presenta un caso clínico con revisión de la literatura

Micosis Nasosinusal. Espectro de la Enfermedad / Rhino-sinusal mycosis: range of the disease

Introducción. Las micosis de senos paranasales se han clasificado en invasiva y no invasiva; el tipo de micosis y su comportamiento clínico depende de la interacción entre la competencia inmunológica del paciente y la patogenicidad del microorganismo, en un determinado micro ambiente. Material y Métodos. Se realizó un estudio clínico prospectivo para evaluar las características de pacientes con sinusitis micótica. Se presentan todos los pacientes diagnosticados y tratados como sinusitis micótica en el periodo de 1994-1997. Resultados. Se encontraron 10 pacientes que correspondieron al 6 por ciento de los casos de sinusitis crónica tratados quirúrgicamente; Todos los pacientes con mucormicosis aguda invasiva recibieron tratamiento medico con anfotericina B, Insulina y refección quirúrgica con debridación extensa del tejido necrótico, resultando en control de la enfermedad subyacente y sobrevida del 50 por ciento de los pacientes. Conclusión. Es necesario diagnosticar precozmente, y dar tratamiento multi disciplinario médico y quirúrgico para lograr una mejor supervivencia de los pacientes

Valor de la secresión rinosinusal como método diagnóstico de sinusitis bacteriana aguda / The rhinosinusal secretion as a diagnostic method of acute bacterial sinusitis

El diagnóstico etiológico de la sinusitis aguda, se logra por medio de muestras obtenidas por punción sinusal. Dado que ésta a menudo es evitada por ser una técnica cruenta, el objetivo de nuestro trabajo fue evaluar si la secreción rinosinusal, según determinados criterios, podría ser considerada como muestra apta para el diagnóstico de sinusitis bacteriana aguda. Se estudiaron 58 casos comparando en cada uno punción sinusal y secreción rinosinusal. Los resultados obtenidos se dividieron en dos grupos de acuerdo a si hubo o no correlación entre ambas muestras y al número de leucocitos polimorfonucleares (PMN) observados por campo en la secreción rinosinusal. De los 20 casos en que la secreción rinosinusal mostró más de 20 leucocitos PMN/campo, 18 (90 por ciento) mostraron resultados comprobables a los de la punción sinusal (p < 0,001) y 14 de ellos presentaban un microorganismo predominante en la coloración de Gram. En los 38 casos restantes con menos de 20 leucocitos PMN, fue frecuente observar escasas bacterias al examen directo y obtener desarrollo de varias especies pertenecientes a la flor normal de la región. Concluimos que si el recuento de leucocitos, en una muestra de secreción rinosinusal, supera los 20 leucitos PMN por campo de 40 x y se observa una morfología predominante en el examen directo por coloración de Gram, ésta podría considerarse muestra apta para el cultivo bacteriano

Mycotic infections of nose and paranasal sinuses in immunocompromised and immunocompetent patients

This study was done to compare normal flora of the nose and paranasal sinuses in immuno-competent individuals with that of the immuno-compromised patients, in addition to evaluation of the role of opportunistic fungi in producing mycotic infection of the nose and paranasal sinuses in immunocompromised patients. It was carried out on 150 immunocompromised patients mostly diabetic compared to 150 apparently immunocompetent patients -For each number of the samples, full history and complete E. N.T. examination was done. Also diagnostic nasal endoscopy was done and samples of nasal discharge were collected for culture on Sabouraud'sdextrose agar for myocological culture and be used for follow up. C.T. scan was done for all cases with +ve myocologicol culture. The importance of biopsy taken from suspected lesions for histopathological examination to differntiate invasive from non invasive fungus prior to selecting the appropriate treatment options

Bacteriologia do conteúdo do seio maxilar na imunodeficiência humana / Bacteriology of the maxilar sinus contents in the human immunodeficiency

Foi realizada a pesquisa bacteriológica do conteúdo dos seios maxilares em 18 pacientes aidéticos, atendidos no Hospital do Servidor Público Estadual de Sao Paulo (HSPE), que apresentavam sinais e sintomas compatíveis com sinusite de difícil controle clínico. Eram 12 pacientes do sexo masculino e seis do sexo feminino, com idade média de 33,5 anos, sendo descritos os seus quadros clínico e obtidos os valores de CD4. O diagnóstico radiológico foi feito por meio de tomografia computadorizada, que mostrou comprometimento de vários seios da face, concomitantemente. A punçao maxilar foi realizada através da fossa canina, após a suspensao temporária dos antiobióticos, por 24 horas. As culturas positivas mostraram os seguintes patógenos: Staphylococcus aureus em quatro culturas, Staphylococcus coagulase negativo em dusas culturas, além de Candida albicans, Candida sp., Haemophilus sp., Streptococcus viridans, Pseudomonas aeruginosa, Proteus mirabilis, Aspergillus sp., Streptococcus pneumoniae, Proteus penneri e Citrobacter diversus em uma cultura cada um. Em sete culturas (38,8 por cento), nao obtivemos crescimento bacteriano ou fúngico. O estudo do material apresentado permite insistir na necessidade de uso de procedimentos agressivos na colheita do material dos seios da face nos aidéticos, para diferentes tipos de culturas e exames bacterioscópicos para a identificaçao do agente patógeno, o que também facilitará o tratamento a ser instituído. Os tratamentos empíricos para tratamento da sinusite nao surtem efeito em pacientes aidéticos.

Micosis oportunistas de senos paranasales: manifestaciones cutáneo-mucosas / Mycoses opportunist of nasal sinuses: manifestations cutaneous-mucosas

Se presentan nueve pacientes con sinusitis fúngica, en el período de 1986-1988. Se aislaron los siguientes agentes etiológicos: Aspergillus flavus (n=3), Alternaria alternata (n=3), Acremonium falciforme (n=1), Rhizopus sp. (n=1), y Cladosporium bantianum (n=1). En individuos inmunocomprometidos (n=8) se observó necrosis de cornetes, tumefacción, edema, obstrucción nasal y rinorrea. En algunos casos estas lesiones progresaron con compromiso de la pared nasal, senos paranasales y cavidad craneal. La mayoría de estos pacientes padecían leucemia mieloide aguda (LMA) y se encontraban en período de neutropenia crítica, asociada a tratamientos quimioterapéuticos. En uno de los pacientes no se detectaron alteraciones inmunológicas. La lesión fue localizada, no invasiva, con congestión nasal y rinorrea. El tratamiento fue anfotericina B en todos los casos, hasta completar 1 g de dosis total. Se comprobó la cura clínica y micológica en cinco de los pacientes, los cuatro restantes fallecieron sin recuperar valores normales de neutrófilos, o corregir su enfermedad de base.

Alternariosis de senos paranasales / Alternariosis of paranasal sinus

Paciente, de sexo femenino , de 47 años de edad, sin antecedentes clínicos de importancia, que presenta una neoformación que ocupa el seno paranasal izquierdo con obstrucción nasal, rinorrea y protrusión del globo ocular del mismo lado. No hay manifestaciones cutáneas. La TC (tomografía computada) muestra una masa ocupante del seno maxilar, etmoides y frontal izquierdo con destrucción de la pared orbitaria, apófisis pterigoides, lámina cribosa del etmoides y desviación del tabique nasal a la derecha. Se efectúa una sinusotomía frontal y del material obtenido se aísla Alternaria alternata. Se realiza tratamiento con anfotericina B, 820 mg dosis total durante un mes. Continúa en forma ambulatoria con grisepfulvina 2 g por día. Finaliza a los dos meses con involución total de las lesiones y controlada por la TC. hasta la fecha no se ha demostrado en nuestra paciente signos de inmunodeficiencia