Atypical mycobacterium detection in refractory chronic rhinosinusitis.

OBJECTIVES: Atypical mycobacterium (AM) involvement in refractory chronic rhinosinusitis (CRS) is sought by some surgeons with customary acid-fast bacilli cultures (AFBC) in the operating room (OR). We evaluate our experience with AM in CRS by describing (1) associated risk factors, (2) species identified, and (3) frequency of positive cultures in clinic versus OR. STUDY DESIGN: Case series with chart review. SETTING: Tertiary rhinology practice. SUBJECTS AND METHODS: AFBC taken between 2005 and 2011 were identified from a microbiology laboratory database. Charts were reviewed for gender, age, medical history, risk factors for AM, pathogen types, and treatments, with statistical comparison using Pearson χ(2). The benefit of "targeted AFBC" for cases with high clinical suspicion was compared with "customary AFBC" in the OR. RESULTS: Thirty-seven patients were identified with AM, of which 10 had one or more risk factors for AM including foreign body (n = 4), non-HIV immune dysfunction (n = 4), and previous chemoradiation (n = 4). Six different AM species were identified: most frequently Mycobacterium abscessus (57.1%), followed by Mycobacterium avium-intracellulare complex (14.3%) and Mycobacterium chelonae (14.3%). "Targeted AFBC" from the outpatient setting were positive in 10 of 190 (5.3%) patients, whereas 10 of 373 (2.6%) patients of "customary AFBC" in the OR were positive (P = .12). Macrolide therapy was employed in 23 of 37 (62%) patients with AM-associated CRS but was not prescribed in patients with positive "customary AFBC" alone. CONCLUSION: AM-associated CRS is an uncommon condition that can occur in the absence of foreign body or overtly altered innate/adaptive immunity. Indications and efficacy of macrolide therapy, as well as the potential relationships between existence of AM in tap water, AM biofilms, and frequent use of nasal irrigations warrant further investigation in refractory CRS.

Oral antifungal therapy for Fusarium-associated chronic rhinosinusitis.

BACKGROUND: Fusarium is commonly reported as an organism found in fungus-associated chronic rhinosinusitis (CRS) yet it is known to be resistant to commonly used antifungal therapies. The goals of this work are to report the incidence of Fusarium-associated CRS in fungal cultures and to describe the treatment experience with oral antifungal agent aimed at this problem. METHODS: Patients with sinus cultures obtained from 2005 through 2008 were retrospectively identified and their medical records were evaluated. Cultures were obtained in patients with recalcitrant rhinosinusitis when purulent discharge was observed. Patient response to the therapy was measured upon the basis of self reported symptom improvements and endoscopic examination. RESULTS: In this 4-year period 2,570 outpatient fungal cultures were obtained and 194 (7.5%) were positive for Fusarium. These 194 positive cultures appeared in 94 individuals. Thirty-four tested positive multiple times. Twenty-three (24.5%) had severe recalcitrant CRS poorly responsive to standard therapies warranting antifungal therapy aimed at Fusarium. Fifteen individuals were treated with voriconazole, 5 with posaconazole, and 3 with both at separate times. Endoscopic evidence of initial improvement on therapy was evident in 16 of 23 patients (69.6%). Of 18 patients who could comment on their experience with the antifungal treatments, nearly 90% of them reported substantial improvement with the therapy. Nine (9/23; 39.1%) were forced to discontinue oral antifungal therapy due to untoward effects. CONCLUSION: Fusarium appears in 7.55% of outpatient cultures of CRS. Of the patients testing positive for Fusarium, 25% received oral antifungal therapy. A positive response was seen in 16 of 23 (69.6%) while receiving other standard therapies. Since Fusarium is not routinely sensitive to commonly used antifungal agents, it warrants special attention.