Varied Clinical Presentations of Allergic Fungal Rhinosinusitis-A Case Series

Abstract

Fungal sinusitis is broadly classified into invasive and non invasive types. Invasive type presents with fungal hyphae within the mucosa, submucosa, bone, or blood vessels of the paranasal sinuses and includes Acute Invasive Fungal Sinusitis, Acute Fulminant, Chronic Invasive Fungal Sinusitis, Chronic Granulomatous Fungal Sinusitis. Invasive forms of fungal rhinosinusitis are rare and confined to groups of patients who are immunocompromised (Key in Fungal rhinosinusitis). Noninvasive type shows absence of fungal hyphae within the mucosa paranasal sinuses. It includes Allergic Fungal rhinosinusitis, Fungus Ball (fungus mycetoma). The study was performed on a total of 30 patients, in Department of Otorhinolaryngology, at our hospital after getting approved by the Instituitional Human Ethical Committee. We selected 30 patients diagnosed with allergic fungal sinusitis and studied their varied clinical presentations and treatment for a period of 1 year. It was a prospective case series type of study. Patients who presented with symptoms of allergic fungal rhinosinusitis were included. Patients who were referred with complaints of proptosis, diplopia were also included to rule out allergic fungal rhinosinusitis and its complications. Patients diagnosed with chronic granulomatous infection of nose and invasive fungal sinusitis were excluded. Evaluation of patients involved a detailed case history followed by clinical examination and radiologic investigation. After getting proper consent, we did a study of 30 patients who presented to our outpatient department with complaints of sinusitis. Our study included 12 male and 18 female patients. Among these patients, all of them had complaints of frequent allergic rhinosinusitis, nose block, facial heaviness. 12 among them had olfactory disturbances, reduced perception of smell. 4 patients presented with visual disturbances and proptosis which subsided after endoscopic sinus surgery was done.24 among these patients had presence of allergic fungal mucin in their nasal secretions and 10 patients had history of associated atopy and asthma and elevated Ig E levels. And 20 of these patients showed high eosinophil counts. All these patients in our case series were under the age group 22-70 years. These patients were treated with a course of nasal sprays and preoperative steroids in case of extensive polyposis and were taken up for functional endoscopic sinus surgery. Polypoidal mucosa was removed, diseased tissue was cleared, sinus blockage was released and fungal mucin/tissue bits were sent for histopathological analysis, KOH mount and fungal culture. This study included a series of cases which showed a wide range of the various clinical presentations that occur in cases of allergic fungal rhinosinusitis, its diagnosis and treatment. The advantage of this study was we had analyzed a good number of cases with varied presentations. Since AFRS is closely related with EMRS, CRS a proper clinical, radiological and immunological evaluation of the cases help in knowing the correct diagnosis and treatment.

Keywords: Allergy; Fungal culture; Mucin; Polyps; Sinusitis.

Fig. 1

Classification of Fungal sinusitis

Fig. 2

Pathophysiology of fungal sinusitis

Fig. 3

Diagnostic nasal endoscopy of a patient showing discharge with allergic fungal mucin

Fig. 4

Axial view showing mucosal thickening in ethmoids

Fig. 5

Saggital section of CT scan showing sinusitis

Fig. 6

Coronal section of CT scan showing complete occlusion of left maxillary and ethmoids with fungal sinusitis and minimal thinning of bony orbit

Fig. 7

Bent and Kuhn classification of AFRS

Fig. 8

Shows the various clinical presentations of patients with AFRS in our study

Fig. 9

Shows intra operative picture of fungal mucin in left maxillary sinus

Fig. 10

Shows intraoperative picture of endoscopic debridement of the fungal debris from sinuses

Fig. 11

Shows a post operative specimen from left maxillary sinus of a patient who underwent FESS and was sent for KOH, fungal culture and HPE

Fig. 12

KOH of septate hyphae

Fig. 13

HiCHROM Candida agar Green is albicans and pale pink is Candida parapsilosis

Fig. 14

Gram staining of Candida

Fig. 15

Aspergillus fumigatus lactophenol cotton blue

Fig. 16

Aspergillus flavus lactophenol cotton blue

Fig. 17

Culture plate showing Aspergillus fumigatus and candida growth on day 3. Eventually all the inoculation areas grew into Aspergillus fumigatus

Fig. 18

Germ tube test for candida albicans