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Fungal sinusitis in immunocompetent patient: A case report

Authors:
Salman Amiruddin at Universiti Sultan Zainal Abidin | UniSZA
Salman Amiruddin
Balwant Singh Gendeh at Pantai Holdings Berhad
Balwant Singh Gendeh
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initiate treatment before irreversible condition We present a case of fungal sinusitis which arise. It is necessary to distinguish the occur in an immunocompetent patient and invasive disease from the non-invasive as the responded well with sinus clearance under treatment and prognosis are different in each.
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ABSTRACT initiate treatment before irreversible condition
We present a case of fungal sinusitis which arise. . It is necessary to distinguish the
occur in an immunocompetent patient and invasive disease from the non-invasive as the
responded well with sinus clearance under treatment and prognosis are different in each.
clinic settings. Early diagnosis is essential in (Rawal Med J 2013;38: 206-208).
order to avoid high morbidity and mortality Key words: Fungal sinusitis, immunocompetent
patient, aspergillosis.
associated with the destructive disease and to
medial maxillary wall and floor of orbit (Fig 1).
INTRODUCTION
Biopsy was not taken and she was referred for
Fungal infections of the paranasal sinus are
further management.
increasingly recognized entity both in normal
and immunocompromised individuals.
Figure 1: CT scan PNS showing left maxillary sinus lesion
Aspergillosis and Mucormycosis being the with calcification.
commonest of all the fungal infections
involving maxillary sinus manifests as two
distinct entities, a non-invasive and invasive
infection. This case report present a case of
fungal sinusitis which occur in an
immunocompetent patient and responded well
with sinus clearance under clinic settings.
CASE PRESENTATION
A 44-years-old Indonesian lady presented to
ENT department of National Malaysian
University Hospital (UKM Medical Center) with
the complaint of progressive left nasal blockage
associated with foul smelly yellowish nasal
discharge. It started about 6 month ago with an
episode of fever and upper gum infection of 1
On examination, patient was alert, medium built
week duration which subsided after a course of
and not cachexic. There was no obvious
antibiotic prescribed by a general practitioner in
swelling at facial area and no cervical
Indonesia.
lymphadenopathy. Rigid nasal endoscopic
On further history, she denied any symptoms
examination showed widening of left maxillary
that related to chronic rhinosinusitis and it's
sinus opening which was fully occupied with
complication such as meningitis and visual
yellowish and blackish debris (Fig 2). The sinus
disturbances. She was immunocompetent and not
content was suctioned out and revealed about
diabetic. She sought treatment in Private Hospital
20 ml yellowish and blackish debris with fluid.
at Pulau Pinang and CT scan of the brain and
It was sent for histopathological examination,
paranasal sinus showed left maxillary sinus
fungal and bacterial culture and sensitivity.
lesion with focal calcification and thinning of
Case Report
206
Fungal sinusitis in immunocompetent patient: a case report
Salman Amiruddin, Balwant Singh Gendeh
Department of Otorhinolaryngology, UKM Medical Center, Kuala Lumpur, Malaysia
Rawal Medical Journal: Vol. 38. No. 2, April-June 2013
Author Contributions:
Conception and design: Salman Amiruddin
Collection and assembly of data: Salman Amiruddin
Analysis and interpretation of the data: Salman Amiruddin
Drafting of the article: Salman Amiruddin
Critical revision of the article for important intellectual content:
Balwant Singh Gendeh
Final approval and guarantor of the article: Salman Amiruddin,
Balwant Singh Gendeh
Conflict of Interest: None declared
Corresponding author email: salmanim82@gmail.com
Rec. Date: Feb 06, 2013 Accept Date: Mar 03, 2013
Figure 2: Fungus occupying left maxillary antrum. patients, allergic fungal sinusitis appears in
atopic patients, while saprophytic and fungal
3
balls appear in immunocompetent patients.
Historically, the organisms most frequently
encountered in this disease are Mucor,
Aspergillus and Rhizopus. Aspergillosis of the
paranasal sinuses is infrequent and usually
involves the species Aspergillus fumigatus and
Aspergillus flavus. The maxillary sinus is the
4
most commonly affected sinus. An acute
invasive fungal infection of the sinonasal
cavities is a potentially life threatening,
systemic infectious disease requiring more urgent
attention and treatment by an
The left maxillary sinus was irrigated with otolaryngologisthead and neck surgeon, but it is
Gentamycin wash until all the content was 5
difficult to diagnose and treat.
washed out leaving inflamed but intact sinus Treatment must be quickly provided, and
mucosa. She was started on IV Augmentin and requires aggressive surgical debridement and
Flagyl for 1 week. Patient was referred to intravenous antifungal therapy, such as
maxillofacial team as the sinusitis was 6
Amphotericin B. Acute invasive fungal sinusitis
suggestive of dental origin. OPG showed apical can be successfully treated with a combination
fibrosis of left upper molar probably due to 7
of endonasal surgical debridement. An
previous infection. No dental extraction was endonasal approach is more suitable for patients
needed. On daily nasal endoscopic examination, diagnosed in the early stages of the disease.
the sinus mucosa inflammation subsided and Open surgery should be preferred in the
patient discharged symptom free after 1 week. presence of palatinal, intraorbital extension, or
Review the fungal and bacterial culture and 8
intracerebral involvement. Reversing the
sensitivity after 2 week showed no growth and underlying disease process and immunosuppr-
the bacterial culture show mixed growth of 4 ession is as important as surgical and antifungal
types of microorganism. However, the 9
treatments.
histopathological examination revealed the
The prognosis is poor without a correction of
presence of several clusters of fungal composed the underlying predisposing immunocom-
of abundant homogenous, septate hyphae and promised state. Significant complications of
numerous budding yeast. On follow up, she invasive fungal infection may occur after
showed tremendous improvement and need not 6
medical remission. Patients should be followed
to go for endoscopic sinus surgery under long-term, until a resolution of crusting and
general anaesthesia. remucosalization of the sinuses and the
5
cessation of bony sequestration.
DISCUSSION
Fungi has been increasingly recognized as
important pathogens in severe acute and chronic
sinusitis in immunocompromised hosts. They
have been detected in more than 90% of nasal
lavages in immunocompetent patients with
1
rhinosinusitis. The role of fungi is well
established in a few subtypes of rhinosinusitis,
such as acute invasive fungal rhinosinusitis,
2
allergic fungal rhinosinusitis, and fungal balls.
With regard to the immunologic status of the
207 Rawal Medical Journal: Vol. 38. No. 2, April-June 2013
Fungal sinusitis in immunocompetent patient: a case report
6. Parikh SL, Venkatraman G, DelGaudio JM. Invasive
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208 Rawal Medical Journal: Vol. 38. No. 2, April-June 2013
Fungal sinusitis in immunocompetent patient: a case report
... Fungus ball is a non-invasive form of the disease resulting in the accumulation of fungal hyphae in the sinuses in immunocompetent individuals without invading the sinus mucosa, bone, or blood vessels. 5 But, if host immunity deteriorates due to any cause, the fungus ball can progress to an invasive fulminant disease in which the hyphae could erode the sinus wall resulting in facial swelling and pain or obstructing the sinus ostium thus predisposing to secondary bacterial infections. The pathophysiology of fungal sinusitis has not been fully understood yet; but both the genetic background and immune status of the affected hosts have been proposed to be involved in the underlying etiology, along with anatomical disorders causing obstruction, environmental exposure, and the type of fungus. ...
... The most commonly involved sinus is the maxillary sinus. 4,5 The two peaks in the age distribution of fungal sinusitis reported in the literature are the elderly and pediatric population with comorbidities like nasal polyps, immunemediated disorders, cystic fibrosis, etc. 7,8 However, there must always be a high index of suspicion for diagnosing fungi in all age groups. Risk factors include uncontrolled diabetes, any kind of malignancy, post-transplantation patients, those receiving immunosuppressive therapy, and patients with human immunodeficiency virus. ...
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