Fungal diseases of the sinuses.

With recent advances in medicine, fungal diseases are becoming not only better understood, but also increasingly important in the management of patients with paranasal sinus disease. Fungal sinus diseases run the gamut from allergic fungal rhinitis and allergic fungal sinusitis, through fungus balls, to invasive and fulminant fungal sinusitis. Allergic fungal sinusitis may be thought of as the sinus counterpart of allergic bronchopulmonary fungal disease. Patients typically are first seen with chronic sinusitis. They may be atopic, and the peripheral blood often shows elevated IgE levels and absolute eosinophil counts. Such patients may be managed conservatively, requiring only surgical drainage and corticosteroid therapy. Fungus balls are typified by the so-called "aspergilloma." Although patients often have some predisposing factor, such as local tissue hypoxia or massive fungal exposure, most patients are not immunocompromised. Fungus balls may be treated with the traditional Caldwell-Luc operation or with newer endoscopic procedures. Invasive or fulminant fungal sinusitis generally occurs in immunosuppressed patients and merits aggressive surgical excision and debridement, as well as systemic chemotherapy, usually amphotericin B. In this article, we review fungal disease of the paranasal sinuses and present findings from our review of patients with chronic sinusitis.

Distant angiogenesis in a patient with glioblastoma multiforme.

The case of a 42-year-old man with a cerebral glioblastoma multiforme associated with marked neovascularization of the arachnoid of the brain stem and spinal cord is reported. All of the neurological symptoms and signs were referrable to the glioblastoma and resultant craniotomies. The arachnoid contained a proliferation of well differentiated blood vessels. This neovascularization occurred in the absence of local tumor or inflammation. We suggest that the neovascularization resulted from release of a tumor angiogenesis factor into the cerebrospinal fluid.

Thecal metaplasia in the adrenal gland of a man with acquired bilateral testicular atrophy.

Thecal metaplasia of the adrenal was observed as an incidental autopsy finding in a 77-year-old man with acquired bilateral testicular atrophy, probably secondary to previous bilateral inguinal herniorrhaphy. The metaplastic focus was composed of interlacing bundles of spindle cells attached to the adrenal capsule, strongly resembling ovarian theca. A related finding was hyperplasia of the anterior pituitary, involving particularly the basophils. We believe that the acquired gonadal failure of this man may have led to increased activity of the pituitary gonadotropes. Blastema cells outside of the testes with the ability to form gonadal stroma, such as cells of the adrenal capsule, were thereby stimulated to undergo metaplasia, giving rise to ovarian theca. Similar thecal metaplasia has been described previously in the adrenals of postmenopausal women. Whether the metaplastic foci are capable of hormone production is not known. Since this patient had an occult prostatic carcinoma at autopsy, potential hormone production by such metaplastic gonadal stroma is clinically relevant.