Acute Invasive Fungal Rhinosinusitis: Frozen Section Histomorphology and Diagnosis with PAS Stain.

Acute invasive fungal rhinosinusitis (AIFRS) is a fulminant infection in immunocompromised patients requiring rapid diagnosis (DX), frequently made on frozen section (FS) of sinonasal biopsies, followed by prompt surgical debridement. However, FS interpretation is often difficult and DX sometimes not possible. In this study we sought to characterize reasons for misinterpretation and methods to improve diagnostic accuracy. The FS slides from 271 biopsies of suspected AIFRS in a 16-year period were reviewed and the morphologic features evaluated for their utility in DX. Recurring specific patterns of necrosis were identified, which to our knowledge have not been described in the literature. Although they provide strong evidence for AIFRS, identifying fungus consistently in necrotic tissue is essential for DX. Clues to identifying fungus and pitfalls in misidentification were identified, but even with expert knowledge of these, a gap in accurate DX remained. The key to FS DX of AIFRS is to improve fungus identification in necrotic tissues. Methods had been sought in the past to stain fungus at FS without consistent success. The Periodic Acid Schiff's Reaction for Fungi was modified by our histopathology department for use on frozen tissue (PASF-fs) resulting in effective staining of the fungus. It stained fungus on all 62 positive slides when applied retrospectively over hematoxylin and eosin (H&E) stained FSs and used prospectively at FS for DX. Although knowledge of histologic morphology on FS is important, the crucial value of this study is the novel use of PASF-fs to identify fungus in the DX of AIFRS.

Frozen Section as a Rapid and Accurate Method for Diagnosing Acute Invasive Fungal Rhinosinusitis.

Objective Identify methods to improve the frozen-section diagnosis of acute invasive fungal rhinosinusitis. Study Design Biopsies with frozen section for suspected acute invasive fungal rhinosinusitis were reviewed to identify causes for missed diagnoses and evaluate methods for potential improvement. Setting All aspects of the study were performed at the Penn State Milton S. Hershey Medical Center. Subjects and Methods All frozen sections performed for suspected acute invasive fungal rhinosinusitis between 2006 through 2017 were reviewed with their diagnoses compared to the final diagnoses. Sensitivity and specificity were determined for each biopsy specimen to evaluate the diagnostic method and for each patient for its effectiveness on outcome. Causes for frozen-section failures in diagnosis were identified. A periodic acid-Schiff stain for fungus (PASF) was modified for use on frozen tissue (PASF-fs) and applied both retrospectively and prospectively to frozen sections to determine its ability to identify undetected fungus and improve diagnostic sensitivity. Results Of 63 biopsies positive for acute invasive fungal rhinosinusitis, 51 were diagnosed on frozen section, while 61 were identified by including the novel PASF-fs stain, reducing the failure rate from 19% to 3%. Of 41 cases that were positive, 34 were diagnosed on frozen section. Of the 7 that were not, 5 were identified by including the PASF-fs, reducing the failure rate from 17% to 5%. Conclusions Frozen section interpretation of biopsies for suspected acute invasive fungal rhinosinusitis using a PASF-fs stain should enable a rapid and accurate diagnosis with improved outcomes by shortening the time to surgery.

In vitro effects of anthocyanidins on sinonasal epithelial nitric oxide production and bacterial physiology.

BACKGROUND: T2R bitter taste receptors play a crucial role in sinonasal innate immunity by upregulating mucociliary clearance and nitric oxide (NO) production in response to bitter gram-negative quorum-sensing molecules in the airway surface liquid. Previous studies showed that phytochemical flavonoid metabolites, known as anthocyanidins, taste bitter and have antibacterial effects. Our objectives were to examine the effects of anthocyanidins on NO production by human sinonasal epithelial cells and ciliary beat frequency, and their impact on common sinonasal pathogens Pseudomonas aeruginosa and Staphylococcus aureus. METHODS: Ciliary beat frequency and NO production were measured by using digital imaging of differentiated air-liquid interface cultures prepared from primary human cells isolated from residual surgical material. Plate-based assays were used to determine the effects of anthocyanidins on bacterial swimming and swarming motility. Biofilm formation and planktonic growth were also assessed. RESULTS: Anthocyanidin compounds triggered epithelial cells to produce NO but not through T2R receptors. However, anthocyanidins did not impact ciliary beat frequency. Furthermore, they did not reduce biofilm formation or planktonic growth of P. aeruginosa. In S. aureus, they did not reduce planktonic growth, and only one compound had minimal antibiofilm effects. The anthocyanidin delphinidin and anthocyanin keracyanin were found to promote bacterial swimming, whereas anthocyanidin cyanidin and flavonoid myricetin did not. No compounds that were tested inhibited bacterial swarming. CONCLUSION: Results of this study indicated that, although anthocyanidins may elicited an innate immune NO response from human cells, they do not cause an increase in ciliary beating and they may also cause a pathogenicity-enhancing effect in P. aeruginosa. Additional studies are necessary to understand how this would affect the use of anthocyanidins as therapeutics. This study emphasized the usefulness of in vitro screening of candidate compounds against multiple parameters of both epithelial and bacterial physiologies to prioritize candidates for in vivo therapeutic testing.

Acute Invasive Fungal Rhinosinusitis: A 15-Year Experience with 41 Patients.

OBJECTIVES: To describe a 15-year single-institution experience of 41 cases of acute invasive fungal sinusitis (AIFRS), identify clinical indicators predictive of AIFRS, and discuss our approach to these high-acuity patients. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center; The Pennsylvania State University Hershey Medical Center. SUBJECTS AND METHODS: A retrospective review was performed for AIFRS consultations between September 1999 and March 2014. Variables reviewed included underlying condition, presenting symptoms, absolute neutrophil count, disease extent on examination, radiographic findings, medical treatment, biopsy results, surgical treatment, and outcomes. Univariate analysis was performed to determine variables significantly associated with AIFRS. Outcome measures were assessed and patient assessment algorithm developed. RESULTS: Of 131 patients evaluated, 41 were diagnosed with AIFRS; 92.7% had an underlying hematologic malignancy. Disease predictive variables included absolute neutrophil count <500/µL (P < .0001; sensitivity = 78%), mucosal abnormalities of middle turbinate (P < .0001; specificity = 88%) and septum (P < .0001; specificity = 97%), and specifically, necrosis of the middle turbinate (P < .0001; specificity = 97%). Twenty-five AIFRS patients (61%) survived until discharge; 25% (n = 10) expired secondary to AIFRS infection explicitly. CONCLUSION: This series represents one of the largest single-institution experiences of AIFRS published to date. Timely diagnosis is necessary to improve patient outcomes and limit morbidity. Maintaining a high index of suspicion in at-risk patient populations, followed by prompt evaluation and management, is crucial in suspected AIFRS. The presence or absence of certain findings appear to correlate with biopsy results and may aid in appropriately gauging clinical suspicion for the presence of AIFRS.

Radiographic evaluation of non-localizing parathyroid adenomas.

PURPOSE: Patients with primary hyperparathyroidism routinely undergo preoperative imaging to localize the abnormal gland to facilitate a guided parathyroidectomy. These techniques include neck ultrasound (US), dual phase planar technetium-99m ((99m)TC) sestamibi (MIBI) scans, single photon emission computed tomography (SPECT), combined SPECT/CT, and four dimensional CT scans (4D CT). Despite appropriate preoperative imaging, non-localization of abnormal glands does occur. This study aims to determine whether non-localization is the result of radiologic interpretive error or a representation of a subset of truly non-localizing parathyroid adenomas. MATERIALS AND METHODS: A retrospective study was performed; two senior radiologists reinterpreted the preoperative imaging (US and MIBI scans) of 30 patients with initially non-localizing studies. All patients underwent parathyroidectomy for primary hyperparathyroidism at a tertiary referral center. Both radiologists were blinded to the scores of his colleague. The results were compared for inter-reader reliability using Cohen's kappa test. RESULTS: Twenty-nine of thirty nuclear studies were found to be negative on reinterpretation. The readers agreed in 86.67% of their observations, with a kappa (κ) value of 0.706 (SE=±0.131, 95% confidence interval for κ =0.449-0.962). One of eighteen ultrasounds had positive localizations on reexamination, however, the inter-observer agreement was only 55.6%, with a kappa value of 0.351 (SE=±0.139, and 95% confidence interval for κ =0.080-0.623). Overall, no statistically significant difference in preoperative and retrospective interpretation was found. CONCLUSION: This study identifies a subset of parathyroid adenomas that do not localize on preoperative imaging despite sound radiographic evaluation.