'CT and CT image-based texture image analysis in radiological diagnostics of allergic fungal rhinosinusitis'.

BACKGROUND: This prospective study is focused on evaluating radiological properties of AFRS. We analysed specific CT features related to the presence of AFRS, as well as explored the possible usefulness of the texture image analysis (TIA) as an additional diagnostical parameter. METHODS: The CT images of maxillary sinuses of 37 adult patients diagnosed with chronic rhinosinusitis were analysed for homogeneity, high-attenuation areas, density of the soft tissue mass, bony wall thickness and density. TIA included assessment of uniformity, contrast, homogeneity and entropy of sinus content. RESULTS: In the F+ group, soft tissue mass was significantly more non-homogeneous, high-attenuation areas were more prevalent, while soft tissue densities were higher. The sinus wall showed a tendency towards decreased thickness and significantly higher density in the F+ group. Among TIA parameters only homogeneity was significantly lower in the F+ group. CONCLUSIONS: Presence of fungi should be suspected when the sinus is filled with a non-homogenous soft tissue content of a high CT density not necessarily presented as clearly visible hyperattenuation material. Additional criteria in radiological diagnostics of AFRS should encompass assessment of sinus bony wall density. TIA may serve as a tool for quantitative assessment of subjective CT features such as homogeneity of the soft tissue mass for investigative purposes. However, other TIA parameters showed limited potential.

Study toward resolving the controversy over the definition of allergic fungal rhinosinusitis.

Dysbiosis of the microbiome on the airway mucosa leads to the development of chronic inflammatory and allergic disorders. The aim of this study was to consider the potential diagnostic criteria for allergic fungal rhinosinusitis (AFRS) and nonallergic fungal rhinosinusitis (FRS), and the role of fungal presence in an environment for the development of AFRS. In this study, 136 patients were divided into two groups: patients with positive specific immunoglobulin E (sIgE) and fungal finding (AFRS group), and patients with negative sIgE and positive fungal finding (FRS group). The study design included: anamnesis data, sIgE, eosinophil count and skin-prick test, rhinology and computerized tomography (CT) observation and mycological finding. Our results showed: (i) the prevalence in Serbia is: AFRS 1.3%, FRS 2.8%; (ii) 30.4% patients with sIgE+ had more often severe and recurrent chronic rhinosinusitis (CRS) (P = .005) and the presence of polyps (P = .025); (iii) 46.4% patients with sIgE+ had positive fungi on the sinonasal mucosa and were considered as AFRS; (iv) patients with AFRS had more frequent asthma (P = .024) and chronicity of CRS >10 years (P = .000). The persistent fungal presence and prolonged duration of CRS could be a silent threat for the progression of inflammation and development of FRS. Lavage with hypertonic-NaCl should be included in the everyday hygiene routine in an effort to decrease fungal load and antigenic exposure. The presence of allergological parameters and better response to corticosteroid therapy in AFRS patients should be considered as crucial diagnostic criteria for AFRS.

Contralateral sinus involvement of surgically treated unilateral allergic fungal rhinosinusitis.

Recurrence of allergic fungal rhinosinusitis (AFRS) is well recognized. However, there is scarcity in the literature describing involvement of the non-diseased sinuses. We aimed to evaluate the recurrence forms of unilateral AFRS as well as to study the possible predictor factors of developing the disease in the contralateral side. Patients with exclusive unilateral AFRS from (2010 to 2015) were enrolled in multi-institutional case-control study. All patients were evaluated after endoscopic sinus surgery for recurrence. Patient's records were reviewed for demographics, medical treatment, and clinical, radiological, and surgical data. A total of 68 patients were identified. Delayed contralateral involvement after the initial surgery was found in 30.8% with mean duration of recurrence 16.9 months. A significant association was found with the presence of pre-operative contralateral symptoms and signs of inflammation (OR 3.49, 95% CI 1.19-10.22, p value 0.02). Post-operative use of budesonide irrigation was associated with less contralateral involvement (OR 0.11, 95% CI 0.01-0.87, p value 0.01). Association of other variables like: comorbidities, perioperative use of systemic steroid, radiological signs, extent of surgery, additional surgery to the contralateral side, and post-operative use of systemic steroids did not show statistical significance. Involvement of the contralateral sinuses in 30% of unilateral AFRS cases is considered significant. The non-diseased sinuses should be involved in the routine endoscopic examination and post-operative treatment. Further studies are necessary to investigate the possibility of prophylactic surgical intervention of the non-diseased sinuses.

Identification of nasal bacterial flora profile and carriage rates of methicillin-resistant Staphylococcus aureus in patients with allergic rhinitis.

The aim of the present study was to evaluate the effect of allergic rhinitis (AR) on the nasal flora and colonization rates of resistant microorganisms in comparison to healthy individuals. This colonization may be important in terms of AR-related disorders, the resistant microorganisms' carriage, and its complications and co-morbidities. The study was performed with two groups. The study group was composed of 54 adult patients with AR. The control group was composed of 50 healthy individuals. None of the individuals in both groups have used any antibiotics, local or systemic steroid within the last month. Composition of bacterial nasal flora and carriage rates of methicillin-resistant Staphylococcus aureus (MRSA) were evaluated with conventional methods by taking nasal smears with a swab. In the study group, methicillin-sensitive coagulase-negative staphylococci (MRCNS) were detected in 30%; whereas diphtheroids in 25%, methicillin-resistant coagulase-negative staphylococci in 13%, methicillin-sensitive S. aureus in 9%, methicillin-resistant S. aureus in 3.7%, and extended-spectrum beta lactamases-positive gram-negative bacilli (GR-ESBL+) in 3.7% were detected. In the control group, methicillin-sensitive coagulase-negative staphylococci were detected in 54%; whereas diphtheroids in 21%, methicillin-resistant coagulase-negative staphylococci in 1.5%, methicillin-sensitive S. aureus in 16%, methicillin-resistant S. aureus in 1.5%, Gr-ESBL(-) in 4%, and viridians streptococci in 3% were detected. It is found that the MRSA and MRCNS colonization is higher in patients with AR. This colonization may be important in terms of AR-related disorders, the resistant microorganisms' carriage, and its complications and co-morbidities in comparison to healthy subjects.

Impact of fungal load on diagnosis and outcome of allergic fungal rhinosinusitis.

Fungal load colonization may modify the classic eosinophilic inflammation in allergic fungal rhinosinusitis (AFRS). We aimed to evaluate the impact of fungal load on diagnosis and outcome of AFRS. In the present cohort study fungal load differences were determined prospectively according to Gomori methenamine silver (GMS) fungal stained (histopathological and cytological examination) with the tenacious mucus, cheesy clay-like materials and sinus mucosa/polyps in 12 AFRS patients. Two groups with different fungal loads, AFRS with (six patients) and without (six patients) high fungal loads (HFL) were evaluated for nasal endoscopic score, paranasal sinuses CT score, histopathological and immunohistochemical changes. Endoscopic outcome scoring differences were evaluated for 1 year after endoscopic sinus surgery and 1 month oral corticosteroids treatment. No differences were observed between both groups (AFRS with/without HFL) concerning the total CT score and opacification features (P > 0.05). Eosinophils and CD3 + CD8 + T cell were dominant in both groups. More edema and less fibrosis were observed in HFL group. Gliotoxin producers Aspergilli were present in all HFL in comparison to 5/6 (83.3%) in cases without HFL. Fewer patients 1/6 (16.6%) and less number of recurrences/year 0.1 ± 0.4 occurred in the AFRS with HFL compared to the AFRS without HFL [5/6 (83.3%) and 1.16 ± 0.7) (P = 0.021 and 0.023, respectively]. In addition to mucus and mucosal tissues, cheesy clay-like materials must be assessed in AFRS cases. Although patients of AFRS with HFL had negligible clinical differences from ordinary AFRS without HFL, they had better outcome after treatment.

Pseudotumoral allergic fungal sinusitis with skull base involvement.

Here we report a case of pseudotumoral recurrence of allergic fungal sinusitis with involvement of the skull base that was successfully treated with systemic corticosteroids and itraconazole without surgery. This report discusses the sometimes misleading radiological and clinical features as well as the diagnostic and therapeutic challenges of a condition that should be recognized by ENT specialists, neurosurgeons, ophtalmologists and radiologists.

[Two cases of allergic fungal rhinosinusitis with bone destruction].

We report herein two cases of allergic fungal rhinosinusitis accompanied by bone destruction of the adjacent nasal sinuses. The first case involved a 21-year-old man who presented with left exophthalmos. Computed tomography (CT) showed soft tissue lesions in the left paranasal sinuses and destruction of the left lamina papyraceae, as well as infiltration of the lesion into the orbit. In the second case, a 39-year-old man, CT showed bone destruction of the skull base and medial wall of the left orbit. In both cases, total serum immunoglobulin (Ig)E level was >1000 IU/mL and fungus-specific IgEs were increased. Fungal hyphae were identified within the mucus on histopathological examination in both cases; however, no fungal invasion of the mucosa was apparent. Final diagnosis was allergic fungal rhinosinusitis (AFRS) in both cases. AFRS is a relatively new disease concept that was proposed in the early 1980s, with disease characteristics very similar to eosinophilic rhinosinusitis. Occasionally, AFRS must be differentiated from malignant disease or invasive fungal rhinosinusitis, so an understanding of the clinical features is important.

The effect of topical mometasone furoate nasal spray on carriage of Staphylococcus aureus.

OBJECTIVES: This study aims to examine the effect of topical mometasone furoate nasal spray on nasal Staphylococcus aureus (S. aureus) colonization in the treatment of allergic rhinitis. PATIENTS AND METHODS: Between January 2012 and February 2013, 53 patients having perennial allergic rhinitis symptoms (37 females, 16 males) and 53 healthy controls (36 females, 17 males) were included in the study. Nasal cultures were obtained and evaluated before and after the treatment in allergic rhinitis patients who were admitted to the ear, nose and throat (ENT) outpatient clinic and receiving a mometasone furoate nasal spray treatment (200 mcg/day) once a day for one-month. In healthy controls, nasal cultures were obtained and evaluated once. RESULTS: In allergic rhinitis patients, five cultures were positive for S. aureus before the treatment while the number of cultures positive for S. aureus was six after the treatment. There was no significant difference in the pre-treatment and post-treatment S. aureus colonization between the patient group and controls (p>0.05). CONCLUSION: Mometasone furoate nasal spray used in the treatment of allergic rhinitis appears to be ineffective for nasal S. aureus colonization.

Frequency of fungal isolation and antifungal susceptibility pattern of the fungal isolates from nasal polyps of chronic rhinosinusitis patients at a tertiary care centre in north India.

Sinonasal polyposis is considered to be the end-result of a chronic inflammatory process in the sinonasal mucosa. Its underlying mechanisms are still unclear, but the involvement of fungi has been suggested for many years. In the present study, we retrospectively evaluated the clinical and mycological profile of 161 patients with chronic rhinosinusitis (CRS) and nasal polyps who were undergoing surgery at our tertiary care facility during 2002 to 2010. CT scan findings and per-operative presence of allergic mucin were provisionally suggestive of fungal rhinosinusitis (FRS) in all the patients. Total serum IgE and peripheral eosinophilia were noted. Histological examination of polyp tissue showed eosinophilic mucin in 100% of the cases and the incidence of allergic fungal rhinosinusitis (AFRS) was 83.9% in the patient population. KOH and/or culture were positive for fungal hyphae or yeast in 93% (150/161) of the patients. Aspergillus spp. were the most commonly recovered isolates (70%). MICs of all A. flavus and A. fumigatus isolates were within the susceptible zone for itraconazole, voriconazole, and amphoterecin B. In conclusion, allergic fungal rhinosinusitis (FRS) is a common disorder in patients with sinonasal polyposis and due to its recurrent and intractable nature, a high degree of clinical suspicion for the presence of FRS in nasal polyposis should be considered.

Assessment of biofilm by nasal cytology in different forms of rhinitis and its functional correlations.

BACKGROUND: Recently, it has been reported that nasal cytology in light microscopy can identify biofilms, which appear as cyan-stained "Infectious Spots". We assessed by the same method and in the same population, the presence of biofilms in different nasal disorders, and estimated if a correlation with the functional grade of obstruction existed. METHODS: Subjects suffering from different nasal disorders, after a detailed clinical history and ENT examination, underwent nasal fibroendoscopy, skin prick test, rhinomanometry and nasal cytology. The presence of biofilm was linked to the type ofdisease and to the grade of obstruction. RESULTS: Among 1,410 subjects previously studied, the infectious spot was found in 107 patients (7.6%), and this percentage reached 55.4% in subjects with cytologic signs of infectious rhinitis (presence of bacteria/fungi). Biofilms were largely more frequent in patients with adenoid hypertrophy (57.4%), followed by nasal polyposis (24%), chronic rhinosinusitis (9.5%) and non-allergic rhinitis (7.6%). Nasal cytology was normal in the remaining patients, where no infectious spot was detectable. Statistical analysis showed that nasal resistances were significantly higher in presence of biofilms in patients with adenoid hypertrophy (p = 0.003), nasal polyposis (p < 0.001), chronic rhinosinusitis (p = 0.018) and septal deviation (p = 0.001). CONCLUSION: The results demonstrate that biofilm is present not only in infectious rhinitis, but also in inflammatory and/or immune-mediated diseases. The presence of biofilms significantly correlates with the degree of nasal obstruction as assessed by rhinomanometry.

[Allergic rhinosinusitis by Curvularia inaequalis (Shear) Boedijn]. / Rinosinusitis alérgica por Curvularia inaequalis (Shear) Boedijn.

Curvularia inaequalis (Shear) Boedijn is a fungus dematiaceo, saprophyte and plant pathogen found mainly in tropical and subtropical areas, associated with various organic substrates. Rarely been identified in systemic infections, skin and there is only one report of allergic rhinosinusitis described above. A case of allergic fungal rhinosinusitis by Curvularia inaequalis (Shear) Boedijn in which diagnosis was considered the signs and symptoms, sinus CT and cultivation of mucin.The patient was treated with endoscopic surgical toilet, plus use of inhaled steroids and itraconazole systemic. With good clinical response, is asymptomatic at one year.

The impact of Helicobacter pylori on atopic disorders in childhood.

BACKGROUND: The prevalence of Helicobacter pylori in Western populations has steadily decreased. This has been suggested as one of the factors involved in the recent increase of asthma and allergy. Some studies have reported a negative association between H. pylori and asthma and allergy, but data are inconsistent and there are a few studies in children. AIM: We investigated whether the prevalence of H. pylori was associated with asthma symptoms, allergic rhinitis, and atopic dermatitis in childhood. METHODS: We determined IgG anti-H. pylori and CagA antibodies in serum of Dutch children, who took part in the PIAMA birth cohort study. Serum was collected from 545 children, aged 7-9 years (Dutch ethnicity 91.5%). Symptoms of asthma and atopy were assessed by yearly questionnaires. Chi-square tests and logistic regression were used. RESULTS: We found 9%H. pylori and 0.9% CagA seropositivity. Twelve (5.9%) children with reported wheezing ever were H. pylori positive, compared to 37 (10.9%) of the non-wheezers (p = .05). No significant differences in H. pylori prevalence were found between children with or without allergic rhinitis (8.5% vs 9.5%), atopic dermatitis (8.7% vs 9.2%), and physician-diagnosed asthma (7.1% vs 9.4%). Multivariate analysis showed no significant associations between H. pylori seropositivity and wheezing (OR 0.52; 95% CI 0.25-1.06), allergic rhinitis (OR 0.96; 95% CI 0.51-1.81), atopic dermatitis (OR 1.05; 95% CI 0.56-1.98) or physician-diagnosed asthma (OR 0.87; 95% CI 0.37-2.08). CONCLUSION: We found a borderline significantly lower H. pylori seropositivity in children with wheezing compared to non-wheezers, but no association between H. pylori serum-antibody status and allergic rhinitis, atopic dermatitis, or asthma.

Increased diversity of fungal flora in the vagina of patients with recurrent vaginal candidiasis and allergic rhinitis.

Recurrent vaginal candidiasis (RVC) is considered to be a hypersensitivity disorder that is associated with allergic rhinitis (AR) in immune deficiencies; however, whether or not the composition of the vaginal fungal flora in patients with AR and RVC is altered and if such alterations in patients with AR are associated with the development of RVC remain unclear. In the present study, a cultivation-independent method with the 18S rRNA gene clone library was used to analyze the diversity and composition of the vaginal fungal flora in patients with AR and RVC and to explore the association. Three fungal phyla (Ascomycotae, 22 out of 28; Basidiomycetes, 5 out of 28; and Oomycetes, 1 out of 28) were identified from groups of healthy volunteers, patients with AR, patients with RVC, and patients with RVC complicated by AR, including 28 phylotypes of fungal flora (10, 15, 17, and 21 phylotypes for each group, respectively). The predominant genera of fungi identified in the vagina included Candida, uncultured fungi, and Dothideomycetes. An increased proportion of Candida albicans accompanied with decreased proportions of Saccharomyces cerevisiae and uncultured fungi was observed in patients with AR or RVC (P < 0.05). Candida glabrata, Eladia saccula, Trichosporon jirovecii, and Phytophthora spp. occurred simultaneously in the three patient groups. The composition of the fungal communities in the four groups was statistically different (P < 0.001). The vaginal fungal diversity in patients with AR or RVC was significantly higher compared with healthy volunteers (P < 0.05). The data revealed an increased diversity and varied composition of the vaginal fungal flora in patients with AR and RVC and indicated that disturbed vaginal fungal flora in patients with AR might be correlated with disease progression in patients with RVC.

A prospective study of bacterial flora in nasal cavity of patients with persistent allergic rhinitis.

It remains unanswered whether persistent allergic inflammation in nasal mucosa alters bacterial colonization and infection. The aim of this study was to investigate the bacterial flora in the nasal cavity of patients with persistent allergic rhinitis (PAR) and to correlate the bacteriological findings with presence of nasal symptoms, nasal eosinophil and neutrophil counts. A total of 255 subjects, aged between 6 - 74 years (mean 33.9 years) was randomly selected from a population-based rhinitis survey study in Singapore. All subjects went through a thorough medical history and nasal examinations. Serum specific IgE to a panel of common house dust mites, nasal cytological and microbiological examinations were performed. PAR was diagnosed in 107 patients and none of them had received previous regular therapy. There is a significant relationship between PAR and eosinophil grades, but not with neutrophil count. No statistically significant difference was found in quantitative and qualitative bacterial flora in nasal cavity between PAR patients and subjects with non-rhinitis or with non-allergic rhinitis. There is a significant inverse correlation between ongoing rhinorrhoea and quantitative bacterial load, and between signs of nasal mucosa (pale and edema) and the presence and type of bacterial pathogens. In conclusion, our study demonstrates that patients with untreated (or using PRN medicine) PAR do not result in a significant change in bacterial flora in their nasal cavity.

Respiratory health in children, and indoor exposure to (1,3)-ß-D-glucan, EPS mould components and endotoxin.

For a long time, exposure to mould and dampness-derived microbial components was considered a risk factor for the development of respiratory diseases and symptoms. Some recent studies suggested that early childhood exposure to mould components, such as (1,3)-ß-D-glucan and extracellular polysaccharides (EPSs), may protect children from developing allergy. We investigated the association of exposure to (1,3)-ß-D-glucan, EPS and endotoxin with asthma and allergies in 6-yr-old children. This investigation was the follow-up to a nested case-control study among three European birth cohorts. Children from two ongoing birth cohort studies performed in Germany (n = 358) and one in the Netherlands (n = 338) were selected. Levels of (1,3)-ß-D-glucan, EPS and endotoxin were measured in settled house dust sampled from children's mattresses and living-room floors when the children were, on average, 5 yrs of age. At the age of 6 yrs, health outcome information was available for 678 children. In the two German subsets, domestic EPS and endotoxin exposure from children's mattresses were significantly negatively associated with physician-diagnosed asthma (OR per interquartile range increase 0.60 (95% CI 0.39-0.92) and 0.55 (95% CI 0.31-0.97), respectively). In addition, EPS exposure was inversely related to physician-diagnosed allergic rhinitis (OR 0.50, 95% CI 0.31-0.81). For the Dutch population, no associations were observed between exposure to microbial agents and respiratory health outcomes. We found inverse associations between domestic exposure to EPS and endotoxin from children's mattresses, and doctor-diagnosed asthma and rhinitis in German, but not in Dutch, school children. The reasons for the differences between countries are not clear.

Total viable molds and fungal DNA in classrooms and association with respiratory health and pulmonary function of European schoolchildren.

Indoor molds are associated with adverse respiratory effects in children. Although schools are important exposure sources of molds, objective measurements were more often taken in homes. Our aim was to assess indoor molds in schools and related effects on schoolchildren health. The Health Effects of the School Environment study (HESE) included 21 schools (46 classrooms) in Italy, Denmark, Sweden, Norway, and France and 654 schoolchildren (mean age 10 yr). Information on schoolchildren was collected by standardized questionnaires. Measurements of total viable molds (VM, colony-forming units, cfu/m(3)) and total/specific fungal DNA (cell equivalents, CE/g dust) were taken inside all classrooms in the cold season during normal activities, using the same standardized methodology. Pulmonary function tests were performed on 244 pupils. VM (mean, 320,cfu/m(3)) and total fungal DNA (geometric mean, 2.2 × 10(5) ± 2.1 CE/g dust) were detectable in all classrooms. The levels were significantly higher in buildings with mold/dampness problems. VM, but not fungal DNA, were inversely related to ventilation rate. VM exceeded the maximum standard of 300 cfu/m(3) in 33% of the classrooms. In the past 12 months, dry cough at night (34%) and rhinitis (32%) were the mostly reported. Children exposed to VM levels ≥ 300 cfu/m(3), compared with those exposed to lower levels, showed higher risk for past year dry cough at night (odds ratio, OR: 3.10, 95% confidence interval, CI: 1.61-5.98) and rhinitis (OR: 2.86, 95% CI: 1.65-4.95), as well as for persistent cough (OR: 3.79, 95% CI: 2.40-5.60). Aspergillus/Penicillium DNA was significantly positively associated with wheeze, and Aspergillus versicolor DNA with wheeze, rhinitis, and cough. There were significant inverse associations of Aspergillus versicolor DNA with forced vitality capacity (FVC) and Streptomyces DNA with both FEV(1) and FVC. In conclusion, indoor VM and fungal DNA were commonly found in monitored European schools and adversely related to respiratory health. Schools should be routinely tested through both culturable and non-culturable methods for global indoor molds' evaluation.

Skin test reactivity of allergic subjects to basidiomycetes' crude extracts in a tropical environment.

Fungal allergies can be detected by the skin prick test with extracts of the organisms, but not all fungi, including the basidiomycetes, are being examined. We determined the level of sensitization to basidiomycetes in allergic subjects and compared their reactivity to commercial extracts commonly used to detect allergies. Crude spore extracts of the basidiomycetes Ganoderma applanatum, Chlorophyllum molybdites, and Pleurotus ostreatus, which are known to release numerous spores, were examined along with commercial extracts on 33 subjects with asthma, allergic or non-allergic rhinitis. Overall, affected subjects showed the highest reactivity to mites (36%), followed by Ganoderma applanatum (30%), grass (27%) Chlorophyllum molybdites (12%) and Pleurotus ostreatus (12%). Allergic rhinitis patients were most reactive to mites (58%), grass (42%), Ganoderma applanatum (25%), Penicillium spp. (25%), and cat (17%). Those with asthma primarily responded to mites (44%), Ganoderma applanatum (44%), grass (33%), and Pleurotus ostreatus (22%). IgE levels correlated with positive basidiomycetes extracts. This finding, coupled with higher reactivity to basidiospores as compared to mitospores, and the similar sensitivities of patients to G. applanatum and mites, suggest that basidiomycetes are important allergen sources in the tropics.

Allergic fungal sinusitis with massive intracranial extension presenting with tearing.

A 24-year-old male presented with tearing, and subsequent workup and imaging showed a mass with fluid involving the nasopharynx, the paranasal sinuses, and the posterior dehiscence of the left frontal sinus intracranially compressing the frontal lobe significantly. Microscopic examination confirmed the diagnosis of allergic fungal sinusitis. Endoscopic drainage and sinostomy was performed by the otolaryngology (ear-nose-throat) service. The patient was followed 9 months postoperatively and did well with resolution of the epiphora. Although epiphora alone is an unusual presentation of allergic fungal sinusitis, ophthalmologists need to be aware of this entity, as it may invade the orbit through the sinus cavities or compress on the nasolacrimal duct before it causes other mass-related symptoms. Radiology and the characteristic histopathologic findings are the most useful in establishing the correct diagnosis.