Fungi have been identified as emerging cause of rhinosinusitis. Both acute and chronic rhinosinusitis are caused by a variety of fungal agents, most common being Aspergillus species worldwide. In the present study of clinical, radiological and histopathological evaluation was done to determine the type of fungal rhinosinusitis. Antifungal susceptibility testing of all isolates was done, to aid as a guide to determine the prognosis and the most effective line of management.
This prospective observational study was conducted among patients of acute and chronic rhinosinusitis undergoing endoscopic guided sinus surgery. Sinonasal biopsies were processed by standard mycological methods. Further, histopathological examination on H&E, PAS and GMS was done and categorization done. Total serum IgE and absolute eosinophil count were measured to establish a possible correlation, which was determined by ELISA. The antifungal susceptibility testing was done using CLSI M38-A2 protocol.
A total of 106 sinonasal biopsies were received and 51 showed growth of Aspergillus species on culture. Out of total 51, 32 were positive on KOH wet mount (28 had septate, 2 aseptate and 2 had both septate and aseptate hyphae) and 19 were negative. On culture, 46 showed single Aspergillus species and 5 showed mixed infection with two concomitant infecting species. Out of cultures showing single fungal species, 30 had Aspergillus flavus, 6 had Aspergillus fumigatus, 6 had Aspergillus niger and 3 had Aspergillus species. In mixed infections, pairs of fungal species identified were A. flavus + Rhizopus arrhizus, A. niger + Rhizopus arrhizus, A.niger + Penicillium species, A. flavus + A. niger and A. niger + Candida tropicalis. On histopathology, out of 45 cases, 31 had AFRS, 5 had EFRS, 4 had fungal ball, 2 had granulomatous invasive FRS, 2 had acute invasive FRS and 1 had both acute and chronic invasive FRS. Total serum IgE was raised in all cases of AFRS, ranging from
225.50 IU/ml to 1675.10 IU/ml and all had allergic mucin on histopathology. In EFRS, total serum IgE ranged from 13.88 to 178.32 IU/ml and none had allergic mucin on histopathology. In 4 cases of fungal ball, raised IgE was seen in Aspergillus fumigatus (2 cases), A.flavus (1 case) and Aspergillus species (1 case). Total serum IgE was also raised in both cases of granulomatous invasive FRS
(884 and 823 IU/ml) caused by Aspergillus flavus. Of the 52 Aspergillus isolates, 86.53% were susceptible to amphotericin B, 90.38% to itraconazole, 98.07% to voriconazole and 96.15% to caspofungin. All 52 Aspergillus isolates were susceptible to posaconazole, anidulafungin and micafungin; resistant to fluconazole and 5-flucytosine.
Fungal rhinosinusitis is emerging sino-nasal disease that requires an increased awareness of clinicians, radiologists, microbiologist and pathologists. This prevents FRS to cause pressure/invasive effects that can be managed only by surgical removal of fungal mass and conservative treatment. In addition, total serum IgE and absolute eosinophil count are strong indicators towards FRS caused by Aspergillus species due to its profound allergenic effect. Fungal sinusitis should be kept as one of differential diagnosis in such type of presentation so that detection can be made in time.