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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).
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.
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
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
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:
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
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
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
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
cessation of bony sequestration.
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
rhinosinusitis. The role of fungi is well
established in a few subtypes of rhinosinusitis,
such as acute invasive fungal rhinosinusitis,
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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p>The frequency of fungal rhinosinusitis is increasing over the last two decades worldwide. It is classified into two main types: the invasive disease with a poor prognosis which is predominantly seen in patients with some form of immunosuppression and chronic fungal rhinosinusitis usually affecting the immunocompetent individuals. We present a case of fungal sinusitis in an immunocompetent 40-year-old male. The patient had a history of recent onset of progressive nasal blockage, discharge, and cough. Computed tomography scan of paranasal sinuses showed bilateral maxillary, left ethmoidal and sphenoidal sinusitis, and left inferior nasal turbinate hypertrophy. The sample received was necrotic slough from the nose that was processed for histopathology, and special stains, including Grocott’s Methenamine Silver and Periodic Acid Schiff were applied based on which the diagnosis of non-invasive fungal infection was made. Due to early diagnosis, the patient responded well to sinus clearance and conservative management in the clinical setting.</p
Full-text available
Pulmonary complications are the most common cause of morbidity and mortality in immunocompromised patients, who lack of the basic mechanisms of cellular defense. Regardless of the cause of the immunodeficiency, the most common complications are infections (bacterial, viral or fungal). Among the fungal infections, aspergillosis is the most common (incidence, 1-9%; mortality, 55-92%) following organ transplant. Although pulmonary involvement is the most common form of aspergillosis, central nervous system involvement and sinusitis are not uncommon. On CT scans, the halo sign represents an area of low attenuation around the nodule, revealing edema or hemorrhage. The gold standard for the diagnosis is the culture identification of the fungus in sputum, BAL fluid or biopsy samples. Failing this identification, the detection of galactomannan, which is one of the fungal wall components, has shown sensitivity and specificity of 89% and 98%, respectively. Amphotericin B, liposomal amphotericin B, caspofungin and, especially, voriconazole are effective against the fungus. Although Pneumocystis jirovecii pneumonia can be fatal, the incidence of this disease has decreased due to the prophylactic use of trimethoprim-sulfamethoxazole. In immunocompromised patients presenting with dyspnea and hypoxemia, screening for fungi is indicated. A 14- to 21-day course of trimethoprim-sulfamethoxazole in combination with corticosteroids is usually efficacious. Another rare fungal infection is disseminated candidiasis, which is caused by Candida spp.
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The aim of this study was to review our experience with patients with invasive fungal sinusitis (IFS) to determine outcomes and identify factors that may affect patient survival. A retrospective review was performed. Forty-three patients were identified accounting for 45 cases of IFS. The underlying reasons for immunosuppression were hematologic malignancy (28 patients), diabetes mellitus (10 patients), solid organ transplant (3 patients), chronic steroid use (3 patients), and acquired immunodeficiency syndrome (1 patient). Eight of 45 cases (18%) died of IFS. Of the 28 cases associated with hematologic malignanancy, 3 patients died of IFS (11%) and 4 patients (14%) died of other causes with persistent IFS. None of these 7 patients had recovery of their absolute neutrophil count, and all patients who recovered from IFS recovered to a normal absolute neutrophil count. Four of 10 (40%) diabetic patients died of IFS, and 66% of survivors had persistent neurological or visual morbidity. The imortality rate was 29% for patients infected with Mucor and 11% for patients injected with Aspergillus. We have found the overall mortality rate directly related to IFS to be 18%. The rate is higher for diabetic patients than for patients with hematologic causes for their immunosuppression. This is likely because of the higher index of suspicion and early diagnosis and treatment of patients with neutropenia and a less-fulminant, slower-progressing form of IFS from Aspergillus, apparently a less virulent fungus than Mucor. Intracranial involvement and failure to recover from neutropenia are the factors that led to poor prognosis in this series.
Acute invasive fungal rhinosinusitis (AIFRS) is a serious disease with a high mortality and morbidity rate, which almost always affects immunocompromised patients and/or patients with diabetes mellitus. Our purpose was to present the diagnostic and therapeutic management and outcome of these patients. Case series with chart review. Tertiary care university hospital. Twenty-six patients, who were operated on because of AIFRS between September 1999 and June 2009, were retrospectively evaluated in this study. Endoscopic surgery was used in 19 patients, and open surgical debridement was performed in seven patients. Overall survival rate of the patients in the open surgery group (4 of 7; 57.1%) was similar to that of the endoscopically treated group (9 of 19; 47.3%). Thirteen patients (50%) died of complications related to the underlying disease (9 of 13; 69.2%) and AIFRS (4 of 13; 30.7%). AIFRS-specific survival rate is 76.5 percent; 90 percent (9 of 10) and 57.1 percent (4 of 7) for endoscopic and open surgery groups, respectively. Four patients who died had pathological diagnosis of mucormycosis (P = 0.52). AIFRS can be successfully treated with a combination of endonasal surgical debridement and antifungal medications. Endonasal approach is suitable for patients diagnosed in the early stages of the disease and provides a less traumatic option in those patients who already have a poor health status. Open surgery should be preferred in the presence of intraorbital extension, palatinal, and/or intracerebral involvement. Reversing the underlying disease process and immunosuppression is as important as the surgical and antifungal treatment.
Forty each of aspergilli and penicillia were screened for extracellular lipase production on agar plates and in liquid medium containing olive oil as substrate. Twenty-nine aspergilli and twenty-six penicillia produced lipase. Out of these, 19 aspergilli and 22 penicillia showed activity both on Nile blue sulfate and glycerol tributyrate agar plates while only 10 aspergilli and 4 penicillia showed a positive response to glycerol tributyrate agar alone. The screening revealed 11 Aspergillus spp. and 15 Penicillium spp. as new lipase producers. Pig fat as an economic substrate for lipase production was also investigated.
Fungal sinusitis encompasses a wide range of clinical syndromes. Disease is classified into four major categories: 1) acute invasive fungal sinusitis, 2) chronic invasive fungal sinusitis, 3) mycetoma, and 4) allergic fungal sinusitis. Acute disease is most often a fulminant, life-threatening process seen in immunocompromised patients. Treatment requires prompt antifungal therapy and extensive surgical debridement. Other types of fungal sinusitis are more indolent. For chronic invasive sinusitis, a combination of surgical debridement and antifungal agents is the cornerstone of treatment. Mycetomas can usually be extirpated surgically and do not require therapy with antifungal agents. Treatment of allergic fungal sinusitis remains controversial, but most current management regimens utilize surgical debridement combined with corticosteroid therapy, rather than antifungal agents.
To determine the radiographic findings of computed tomographic (CT) imaging most suggestive of invasive fungal sinusitis (IFS) in an immunocompromised patient population. A retrospective review of patients with a diagnosis of IFS reached with CT and confirmed by histopathologic evaluation. An academic tertiary care hospital. Twenty-three immunocompromised patients with confirmed IFS and preoperative CT imaging. Controls were 10 patients with acute myelocytic leukemia and CT evidence of sinusitis but no history of IFS. The CT scans were reviewed to identify factors predictive of invasive fungal disease. Parameters evaluated were nasal cavity and sinus soft tissue thickening, the presence of air-fluid levels, bone erosion, extrasinus extension, and unilateral or bilateral nasal cavity and sinus involvement. The CT findings included severe soft tissue edema of the nasal cavity mucosa (turbinates, lateral nasal wall and floor, and septum) in 21 of the 23 patients, sinus mucoperiosteal thickening in 21, bone erosion in 8, orbital invasion in 6, facial soft tissue swelling in 5, and retroantral fat pad thickening in 2. Two patients had air-fluid levels. No patients had intracranial involvement. Unilateral involvement was found in 21 patients, and bilateral involvement in 2. Review of the control group revealed only mild soft tissue edema of the nasal cavity in 2 (P<.001), unilateral involvement in 2 (P<.001), and evidence of bone erosion or extrasinus soft tissue involvement in none. Most patients do not have classic CT findings of bone erosion or extrasinus extension in the early course of IFS. We found that severe unilateral thickening of the nasal cavity mucosa was the most consistent finding on CT suggestive of underlying IFS, occurring much more frequently in immunocompromised patients with IFS than without IFS. Even though severe nasal cavity soft tissue thickening is much more common in IFS, this is a nonspecific finding that can be seen, to a lesser degree, in all forms of rhinosinusitis. Therefore, the clinician cannot rely solely on CT imaging and must maintain a high index of suspicion when evaluating immunocompromised patients to establish a prompt diagnosis. Early nasal endoscopy with biopsy and initiation of appropriate therapy are necessary to improve prognosis.
Invasive and allergic fungal institution
  • P N Malani
  • C A Kauffman
Malani PN, Kauffman CA. Invasive and allergic fungal institution. Am J Rhinol 2004;18:75-81.
Acute invasive fungal rhinosinusitis: evaluation of 26
  • J M Delgaudio
  • R E Swain
  • Jr
  • T T Kingdom
  • S Muller
DelGaudio JM, Swain RE Jr, Kingdom TT, Muller S, Acute invasive fungal rhinosinusitis: evaluation of 26