Fungal Sinusitis: Current Trends in Diagnosis and Treatment

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Chronic or Indolent Invasive Fungal Sinusitis

Chronic or indolent invasive fungal sinusitis occurs predominantly in immunocompetent and atopic hosts. It is a slowly progressive disease characterized by granulomatous chronic infection that extends beyond the sinus walls. Chakrabarti and associates[18] found an 82.4% incidence of elevated IgE and positive type I hypersensitivity in skin tests to Aspergillus. The invasive nature of the infection can be compared with a locally aggressive neoplasm.[16] Histologically, there may be evidence of bone necrosis along with an infiltrate of lymphocytes, plasma cells, neutrophils, eosinophils, and Langhans' giant cells.[17] Aspergillus or the dematiaceous species are the common causative fungi. Confirmation of the diagnosis is made by biopsy revealing invasion into the surrounding tissues.

This disease occurs predominantly outside of the United States. The majority of reports are from the Sudan and northern India.[17,18] A few cases from the United States were documented by Washburn and colleagues,[17] who discussed 7 patients with chronic or indolent invasive fungal sinusitis, 1 of whom had recently visited the Sudan. As with acute or fulminant invasive fungal sinusitis, once the diagnosis is made, prompt intervention is warranted. Debridement of all involved tissue and bone should be performed. Adjuvant pharmacologic treatment should include amphotericin B. [17] Once fungal cultures and sensitivities are available, ketoconazole or itraconazole may be substituted. With prompt and accurate treatment the prognosis of indolent invasive fungal sinusitis is similar to that of fulminant fungal sinusitis.

There is no consensus regarding the incidence of chronic or indolent invasive fungal sinusitis. In our experience of treating more than 50 patients with allergic fungal sinusitis (AFS), we did not find any cases of chronic or indolent invasive fungal sinusitis. Chakrabarti and colleagues[18] reported that 82.4% of their patients with invasive sinusitis had an elevated IgE, and 92.9% had a positive type 1 hypersensitivity in skin test to Aspergillus,] indicating that chronic or indolent invasive fungal sinusitis is not common. Retrospective review along with newer imaging techniques may suggest that patients previously diagnosed with invasive fungal sinusitis in fact had AFS.

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