Retrospective Analysis of Patients With Acute Invasive Fungal Rhinosinusitis in a Single Tertiary Academic Medical Center: A 10-Year Experience

Abstract

Background Acute invasive fungal rhinosinusitis (AIFRS) is an aggressive, potentially fatal disease that can spread rapidly to the orbit and intracranial structures causing significant mortality and morbidity. Objective In this study, we present a 10-year experience from a tertiary academic medical center of patients presenting with AIFRS. Data on presentation, mortality rate, comorbidities, surgical, and medical management were analyzed. Methods A retrospective chart review was performed in a tertiary academic medical center of patients with AIFRS from January 2009 through February 2019. Data collected included demographics, presenting symptoms, comorbidities, immunosuppression status, endoscopic and imaging findings, orbital and intracranial complications, surgical and medical management, as well as outcomes and mortality. Results A total of 34 patients were identified. In our series, mortality was noted to be 61.8%, excluding patients who were lost to follow-up. The most common presenting symptoms included facial pain, ophthalmologic complaints, headaches, and proptosis. Only 4 of the 34 patients did not undergo surgical intervention, as they were not deemed surgical candidates; they all succumbed to their disease. Twenty-six of the 30 surgical patients (86.7%) underwent endoscopic sinus surgery, 8 underwent an open approach (26.7%), while 7 patients underwent orbital exenteration (23.3%). All patients had surgical pathology consistent with AIFRS. Fungal species isolated from culture included Aspergillus, Mucor/ Rhizopus, Candida, Cunninghamella Scedosporium boydii, Paecilomyces, and Scopulariopsis. Medical therapies included intravenous amphotericin B, caspofungin, posaconazole, voriconazole, isavuconazole, and micafungin. Conclusion AIFRS was associated with 61.8% mortality in our series of 34 patients over the past 10 years. Early diagnosis, as well as rapid and aggressive surgical and medical management, is necessary for optimal outcomes in this devastating disease.

Current Role of Non-Elective Transnasal Endoscopic Surgery: our Experience and Review of The Literature

“…AIFR typically affects immunocompromised patients, and its aggressiveness is due to the ability of the hyphae to invade both mucous membranes and neurovascular structures [44,82]. Elderly, immunosuppressant drugs and diabetes mellitus are all risk factors for immunological impairment and, thus, for fungal infection [43,45].…”

“…Patients with intracranial involvements and/ or without surgical treatment appear to have higher risk of poor outcomes [53,83,84]. A prompt multidisciplinary management is of paramount importance, as estimated disease-specific mortality rate ranges from 14.0 to 61.8% [44,46]. Survivors may require orbital exenteration (2.0 -21.0%) and suffer from devastating sequelae, such as visual loss and cranial nerves palsy [50,52].…”

“…Studies about AIFR included 351 patients, of whom only 5 did not have a primary or secondary immunodeficiency at the time of hospital admission (Table 3) [43][44][45][46][47][48]. 198 patients (56.4%) were treated with TNES, 5 (1.4%) with an open external approach, and 126 (35.9%) with a combination of TNES and open techniques.…”

Role of transnasal endoscopic surgery for the management of orbital diseases

“…Regarding the management of sino-orbital fungal rhinosinusitis, endoscopic sinus debridement slows the progression of the disease, reduces the fungal load and provides a specimen for culture and histopathologic diagnosis with limited morbidities 6,7 . In our cases, the surgical approach was endoscopic in all 5 cases -4 cases with therapeutic intention and one case (candida osteomyelitis) with diagnostic intention alone.…”

Determination of variables for a more accurate diagnostic approach in suspected acute invasive fungal rhinosinusitis: A non‐concurrent cohort study

“…An important element is neutropenia, either functional neutropenia or absolute neutrophil count (ANC) inferior to 500/mL. Other pre‐disposing factors are chronic steroid use, kidney or liver insufficiency, solid organ or bone marrow transplantation, AIDS, iron overload, autoimmune diseases, solid organ cancer, malnutrition and trauma or burns 1,4‐6 …”