Invasive Fungal Sinusitis in the Immunocompromised Pediatric Patient

Abstract

Invasive fungal sinusitis in the pediatric population appears to be a relatively rare entity. An increasing incidence has been noted in accordance with the widespread use of antibiotics, steroids, antineoplastic drugs and radiation therapy. Three illustrative cases are described which outline the initial presenting symptoms, findings on physical examination, computed tomography (CT), intraoperative findings, and histopathologic findings. A review of the literature is presented and a treatment protocol is proposed once a diagnosis is made. Early suspicion and diagnosis are the most important prerequisites for successful treatment which consists of control of the underlying disease, surgical debridement, and systemic antifungal therapy. Cooperation between the otolaryngologist, pediatric specialists, and pathologists are key to the survival of children with invasive fungal sinusitis. Survival in this series was dependent upon return of an immune competent state.

Sinonasal Mucormycosis in Immunocompromised Pediatric Patients

“…Candida albicans and Fusarium are uncommon findings. 2 Mortality is higher when mucormycosis is the causative agent. 3 Four cases of sinonasal mucormycosis are presented in this article.…”

“…In contrast, facial swelling is an unusual finding in the setting of viral or bacterial rhinosinusitis. 2 Nasal mucosal anesthesia can be an early sign of an invasive process preceding objective mucosal lesions, although it can be difficult to elicit in young patients. 3 Bleeding is unusual despite associated thrombocytopenia.…”

“…In aspergillosis, hyphae are large with 45 degree-angle septae, whereas in mucormycosis they are large, irregular, nonseptated, and hardly colored by periodic-acid-Schiff and Grocott stains. 2,3 No specimen should be considered negative for fungal invasion unless a Gomori-methenamine-silver stain has been performed. Histologic confirmation of invasive fungal disease relies on the presence of hyphae in the submucosa, with or without angiocentric invasion and tissue necrosis, with minimal host inflammatory cell infiltration.…”

“…Voriconazole has been approved in 2002 by the Food and Drug Administration for the treatment of invasive aspergillosis and it has been proven more potent than amphotericin B for this indication. [1][2][3]6 Posaconazole has been reported efficient against zygomycetes rhinosinusitis, when first line therapy failed in children above 13 years of age, without significant side effects even with its prolonged use. 11 The use of nasal amphotericin B instillations has been proposed, but their efficacy remains unproven.…”

“…3,6,15,16 There is no doubt that controlling underlying immunosuppressive conditions such as neutropenia (case 2) or diabetes mellitus (case 3), is the most important prognostic factor; it improves control of the disease and prevents its recurrence (case 4). 2,3 A regular follow-up is recommended through repeated CT scans and endoscopic evaluations as needed. Weekly rigid endoscopy is advised until reversal of the underlying condition, followed by a monthly evaluation for 6 months.…”