Invasive Fungal Sinusitis in Immunocompromised Patients: A Multicenter, University Hospital Experience in Shiraz

Mohsen Moghadami, Hossein Ruzbahani, Parisa Badiee, Abolhassan Faramarzi, Payam Peymani, Kamran Bagheri Lankarani

Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
Department of Internal Medicine, Shiraz Uni- versity of Medical Sciences, Shiraz, Iran.
Department of Otolaryngology, Shiraz University of Medical Sciences, Shiraz, Iran.
Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

DOI: 10.4236/aid.2013.34040                

Abstract

Objective: It is to determine the causes of invasive fungal sinusitis in patients of Shiraz University hospitals, Iran. Methods: This cross-sectional study was conducted during 18 months (from 21 March 2009 till 22 September 2010) in three Shiraz University Hospitals. Thirty-six patients with sings of invasive fungal sinusitis were enrolled, and tissue samples were investigated for histopathology, culture and antifungal susceptibility test. The laboratory results with host factor and sinus computed tomography scan were evaluated for classification of patients as proven, probable and possible invasive fungal sinusitis. Results: Thirty-five patients have involved with at least one risk factor (immune compromised disease, diabetes mellitus, or use of immune suppressed drugs). Radiological findings of parasinus invasion or necrosis were present in 20 patients. By histopathology, 21 patients were considered as proven, from these, 17 samples had positive growth. The culture aetiology agents were 4 Candida, 8 Aspergillus, and 5 Mucor. All positive culture samples were matched with histopathology findings. Significant associations were considered for radiologic finding and histopathology and culture (p < 0.05). From 8 patients with mucormycosis histopathology, 6 suffered from diabetes mellitus. None of the antifungal agents were effective on these three types of infections. Conclusion: DM is the most common predisposing factor for IFS followed by ALL and AML. The most common aetiology of IFS was found to be Aspergillus fumigant followed by Mucormycosis and Candida. None of antifungal agents could successfully cover all the species.

 

Keywords

Fungal Sinusitis; Mucor Mycosis; Aspergillus; Invasive Fungal

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	J. Crawford, D. C. Dale and G. H. Lyman, “Chemotherapy-Induced Neutropenia: Risks, Consequences, and New Directions for Its Management,” Cancer, Vol. 100, 2004, pp. 228-237. http://dx.doi.org/10.1002/cncr.11882
[2]	S. Vento and F. Cainelli, “Infections in Patients with Cancer Undergoing Chemotherapy: Etiology, Prevention, and Treatment,” Lancet Oncology, Vol. 4, 2003, pp. 595-604. http://dx.doi.org/10.1016/S1470-2045(03)01218-X
[3]	E. J. Bow, “Management of the Febrile Neutropenic Cancer Patient: Lessons from 40 Years of Study,” Clin Microbiol Infect, Vol. 11, No. S5, 2005, pp. 24-29. http://dx.doi.org/10.1111/j.1469-0691.2005.01240.x
[4]	N. G. Almyroudis and B. H. Segal, “Prevention and Treatment of Invasive Fungal Diseases in Neutropenic Patients,” Current Opinion in Infectious Diseases, Vol. 22, 2009, pp. 385-393. http://dx.doi.org/10.1097/QCO.0b013e32832e074d
[5]	S. Ascioglu, J. H. Rex, B. de Pauw, J. E. Bennett, J. Bille, F. Crokaert, et al., “Invasive Fungal Infections Cooperative Group of the European Organization for Research and Treatment of Cancer; Mycoses Study Group of the National Institute of Allergy and Infectious Diseases. Defining Opportunistic Invasive Fungal Infections in Immunocompromised Patients with Cancer and Hematopoietic Stem Cell Transplants: An International Consensus,” Clinical Infectious Diseases, Vol. 34, 2002, pp. 7-14. http://dx.doi.org/10.1086/323335
[6]	B. De Pauw, T. J. Walsh, J. P. Donnelly, D. A. Stevens, J. E. Edwards, T. Calandra, et al., “European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group; National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/ MSG) Consensus Group. Revised Definitions of Invasive Fungal Disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group,” Clinical Infectious Diseases, Vol. 46, 2008, pp. 1813-1821. http://dx.doi.org/10.1086/588660
[7]	R. Martino and M. Subira, “Invasive Fungal Infections in Hematology: New Trends,” Annals of Hematology, Vol. 81, 2002, pp. 233-243. http://dx.doi.org/10.1007/s00277-002-0466-3
[8]	E. J. Anaissie, “Diagnosis and Therapy of Fungal Infection in Patients with Leukemia—New Drugs and Immunotherapy,” Best Practice & Research Clinical Haematology, Vol. 21, 2008, pp. 683-690. http://dx.doi.org/10.1016/j.beha.2008.10.001
[9]	R. D. deShazo, K. Chapin and R. E. Swain, “Fungal Sinusitis,” The New England Journal of Medicine, Vol. 337, 1997, pp. 254-259. http://dx.doi.org/10.1056/NEJM199707243370407
[10]	S. L. Parikh, G. Venkatraman and J. M. DelGaudio, “Invasive Fungal Sinusitis: A 15-Year Review from a Single Institution,” American Journal of Rhinology, Vol. 18, 2004, pp. 75-81.
[11]	W. T. Anselmo-Lima, R. P. Lopes, F. C. Valera and R. C. Demarco, “Invasive Fungal Rhinosinusitis in Immunocompromised Patients,” Rhinology, Vol. 42, 2004, pp. 141-144.
[12]	R. C. Howells and H. H. Ramadan, “Usefulness of Computed Tomography and Magnetic Resonance in Fulminant Invasive Fungal Rhinosinusitis,” American Journal of Rhinology, Vol. 15, 2001, pp. 255-261.
[13]	C. Y. Chen, W. H. Sheng, A. Cheng, Y. C. Chen, W. Tsay, J. L. Tang, et al., “Invasive Fungal Sinusitis in Patients with Hematological Malignancy: 15 Years Experience in a Single University Hospital in Taiwan,” BMC Infect Disease, Vol. 11, 2011, p. 250. http://dx.doi.org/10.1186/1471-2334-11-250
[14]	P. C. Iwen, M. E. Rupp and S. H. Hinrichs, “Invasive Mold Sinusitis: 17 Cases in Immunocompromised Patients and Review of the Literature,” Clinical Infectious Diseases, Vol. 24, 1997, pp. 1178-1184. http://dx.doi.org/10.1086/513662
[15]	P. E. Drakos, A. Nagler, R. Or, E. Naparstek, J. Kapelushnik, D. Engelhard, G. Rahav, D. Ne’emean and S. Slavin, “Invasive Fungal Sinusitis in Patients Undergoing Bone Marrow Transplantation,” Bone Marrow Transplant, Vol. 12, 1993, pp. 203-208.
[16]	D. Saah, P. E. Drakos, J. Elidan, I. Braverman, R. Or and A. Nagler, “Rhinocerebral Aspergillosis in Patients Undergoing Bone Marrow Transplantation,” Annals of Otology, Rhinology, and Laryngology, Vol. 103, 1994, pp. 306-310.
[17]	G. H. Talbot, A. Huang and M. Provencher, “Invasive Aspergillus Rhinosinusitis in Patients with Acute Leukemia,” Reviews of Infectious Diseases, Vol. 13, 1991, pp. 219-232. http://dx.doi.org/10.1093/clinids/13.2.219
[18]	R. S. Weber and G. Lopez-Berestein, “Treatment of Invasive Aspergillus Sinusitis with Liposomal-Amphotericin B,” Laryngoscope, Vol. 97, 1987, pp. 937-941. http://dx.doi.org/10.1288/00005537-198708000-00010
[19]	A. Wald, W. Leisenring, J. A. van Burik and R. A. Bowden, “Epidemiology of Aspergillus Infections in a Large Cohort of Patients Undergoing Bone Marrow Transplantation,” The Journal of Infectious Diseases, Vol. 175, 1997, pp. 1459-1466. http://dx.doi.org/10.1086/516480
[20]	M. Ruhnke, A. Böhme, D. Buchheidt, K. Donhuijsen, H. Einsele, R. Enzensberger, et al., “Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO) Diagnosis of Invasive Fungal Infections in Hematology and Oncology—Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO),” Annals of Hematology, Vol. 82, No. S2, 2003, pp. S141-S148. http://dx.doi.org/10.1007/s00277-003-0768-0
[21]	D. C. Lanza, H. J. Dhong, P. Tantilipikorn, J. Tanabodee, D. M. Nadel and D. W. Kennedy, “Fungus and Chronic Rhinosinusitis: From Bench to Clinical Understanding,” Annals of Otology, Rhinology, and Laryngology, Vol. 196, No. S1, 2006, pp. 27-34.
[22]	Y. Li, Y. Li, P. Li and G. Zhang, “Diagnosis and Endoscopic Surgery of Chronic Invasive Fungal Rhinosinusitis,” American Journal of Rhinology and Allergy, Vol. 23, 2009, pp. 622-625. http://dx.doi.org/10.2500/ajra.2009.23.3361
[23]	A. P. Ingley, S. L. Parikh and J. M. DelGaudio, “Orbital and Cranial Nerve Presentations and Sequelae Are Hallmarks of Invasive Fungal Sinusitis Caused by Mucor in Contrast to Aspergillus,” American Journal of Rhinology, Vol. 22, 2008, pp. 155-158. http://dx.doi.org/10.2500/ajr.2008.22.3141
[24]	S. Krishnan, E. K. Manavathu and P. H. Chandrasekar, “Aspergillus Flavus: An Emerging Non-Fumigatus Aspergillus Species of Significance,” Mycoses, Vol. 52, 2009, pp. 206-222. http://dx.doi.org/10.1111/j.1439-0507.2008.01642.x
[25]	G. Surya Prakash Rao, S. B. Mann, P. Talwar and M. M. Arora, “Primary Mycotic Infection of Paranasal Sinuses,” Mycopathologia, Vol. 84, 1984, pp. 73-76. http://dx.doi.org/10.1007/BF00436515
[26]	W. A. Bethge, M. Schmalzing, G. Stuhler, U. Schumacher, S. M. Kröber, M. Horger, H. Einsele, L. Kanz and H. Hebart, “Mucormycoses in Patients with Hematologic Malignancies: An Emerging Fungal Infection,” Haematologica, Vol. 90, No. S1, 2005, p. ECR22.
[27]	A. Nosari, P. Oreste, M. Montillo, G. Carrafiello, M. Draisci, G. Muti, et al., “Mucormycosis in Hematologic Malignancies: An Emerging Fungal Infection,” Haematologica, Vol. 85, 2000, pp. 1068-1071.
[28]	A. E. Suslu, O. Ogretmenoglu, N. Suslu, O. T. Yucel and T. M. Onerci, “Acute Invasive Fungal Rhinosinusitis: Our Experience with 19 Patients,” European Archives of Otorhinolaryngology, Vol. 266, 2009, pp. 77-82. http://dx.doi.org/10.1007/s00405-008-0694-9
[29]	R. Y. Hachem, M. R. Boktour, H. A. Hanna, R. Husni, E. Y. Hanna, X. Keutgen, et al., “Sinus Surgery Combined with Antifungal Therapy Is Effective in the Treatment of Invasive Aspergillus Sinusitis in Neutropenic Patients with Cancer,” Infection, Vol. 36, 2008, pp. 539-542. http://dx.doi.org/10.1007/s15010-008-7388-5