Epidemiology and pathogenesis of paranasal sinus mycoses ARUNALOKE CHAKRABARTI, MD, S. C. SHARMA, MS. and J. CHANDER, MD. Chandigarh, India
In a prospective study, 50 cases of paranasal sinus mycoses were diagnosed In 2 years out of 119 clinically suspected patients from north India. Young men from rural areas were most commonly afflicted. Patients with paranasal sinus mycoses could be grouped In three clinical varieties: noninvasive. 31; Invasive, 17; allergic, 2. Maxillary and ethmoid were the common sinuses concurrently Involved In these patients, whereas sphenoid and frontal sinuses were also affected In Invasive variety. Aspergillus flavus (80%) was the most common Isolate. followed by A. fumlgatus (6%). Alternaria species was Identified In two patients with noninvasive granuloma. In Invasive variety. Rhlzopus arrhlzus and Candida alblcans were the causative agents In two patients and one patient, respectively. Regarding pathogenesis besides epidemiologic factors, the trnmunologlc factors were also evaluated. It was found that presence or absence of precipitating antibody against antigens from the etiologic agents correlates well with disease progression. Allergic factor was found In all varieties. though presence of cellmediated Immunity was demonstrated In 29% patients with noninvasive granuloma only. The combination of skin test against aspergillin and precipitin demonstration at the outset will therefore help In preliminary ·screenlng. (OTOlARYNGOL HEAD NECK SURG 1992;107:745.)
P
aranasal sinus mycoses was first reported by Mackenzie' in 1893. Since then. numerous cases were reported from different parts of the world, with higher incidence in the Sudan area.':' Although it is a rare entity in major parts of India-probably as a result of lack of awareness-it is not uncommon in north India.v' Different species of AspergilIus are the causative agents of this entity, with occasional case reports of other fungal involvement.?" The clinical spectrum and pathogenesis of this entity is not clear as yet, but the available data reveal several forms of paranasal mycoses, like noninvasive, invasive, fulminant, and alIergic types. Invasive and fulminant varieties are common in immunocompromised individuals,?" whereas the noninvasive type is more frequently encountered in the nonimmunocompromised hosts." The alIergic form mimics alIergic bronchopulmonary aspergilIosis. '2 In regard to development and progression of the disease, several factors like immu-
From the Department of Medical Microbiology. and ENT. Postgraduate institute of Medical Education and Research. Received for publication May 7, 1992; revision received Aug. 21. 1992; accepted Aug 24. 1992. Reprint requests: Arunaloke Chakrabarti, MD. Department of Medical Microbiology. Postgraduate Institute of Medical Education and Research. Chandigarh-160012. India.
23/1/42364
nologic status," site," duration,":" and presence of alIergyl2,'4 may playa role. Keeping the above facts in consideration, we prospectively evaluated all patients attending our Institute suspected to have paranasal sinus mycoses for 2 years (1990 and 91) to illustrate further the epidemiology and pathogenesis of this entity.
METHODS AND MATERIAL Study population. One hundred nineteen consecutive patients (109 with paranasal sinus granuloma and 10 with chronic maxillary sinusitis) were studied between January 1990 to December 1991. Detailed clinical history and informed consents were taken from these patients. The patients could be characterized into three groups on the basis of clinical features and radiologic findings: I. Patients with symptoms of unilateral/bilateral nasal obstruction, pressure feelings, and nasal discharge with or without nasal polyp (noninvasive variety, 92). 2. Patients with symptoms initialIy confined to one or multiple sinuses and later extended to the orbit or intracranially by means of bone erosion (invasive variety, 17). 3. Patients with symptoms of recurrent sinusitis along with history of asthma (allergic variety, 10). Microbiologic monitoring. Biopsy samples from patients with granuloma and antral wash from patients 745
746
OtolaryngologyHead and Neck Surgery
CHAKRABARTI et 01.
with sinusitis were processed in the microbiology laboratory following standard techniques.":" Direct microscopy in 10% potassium hydroxide and histopathology were performed for demonstration of fungal elements in tissue. All specimens were cultured by inoculation on Sabouraud's dextrose agar for growth of fungi. Different fungal isolates were identified by lactophenol cotton blue mount, slide culture in case of mycelial fungi, and by biochemical tests for yeast
species.":" Patients who were positive for paranasal sinus mycoses and twenty more patients with paranasal sinus granuloma who were negative for fungus etiology (control) were evaluated further by serology and skin test. Serology. Precipitin: Serum samples were collected from control and infected patients. Sera were tested for precipitin by Ochterlony's" gel diffusion techniques, using metabolic antigen of Aspergillus fumigatus, A. fiavus and A. niger. and cytoplasmic protein antigen of Candida albicans prepared according to Longbottom and Peppys" and Syverson et al.," respectively. Eleven antigens were prepared from three species of Aspergillus, using different strains within species isolated from patients with Aspergillosis. All antigens were checked for C-reactive substance before use. In 12 patients (six each with noninvasive and invasive variety) serial testing of sera were performed 2 to 3 weeks after surgery and whenever the symptoms or signs recurred after removal of granuloma mass. Skin test. Intradermal skin tests were performed using 0.1 ml of antigen (1000 PNU / ml Aspergillin, Hollister-Steir, USA) in all patients and controls. Types I (erythema, wheal within I hour) and IV (induration of more than 5 mm diameter after 24 hours) were noted in each case. Total IgE. Enzygnost-IgE monoclonal (Behring) kit was used for demonstration of total IgE after a sandwich enzyme immunoassay procedure. In tubes coated with mouse monoclonal anti-human IgE 20 microliter of test serum (each in duplicate) and 200 microliter of peroxide conjugated mouse monoclonal anti-human IgE were added simultaneously. Positive (300 IU / ml of IgE) and negative controls, each in duplicate, were put with each set of test. After incubation at 37° C for 1 hour, the tubes were washed three times with 2 ml of diluted washing solution (phosphate buffer containing Tween20, supplied with kit), followed by addition of 200 microliter of chromogen (O-phenylenediamine hydrochloride) and buffer-substrate (hydrogen peroxide 0.3 gL -I in citrate buffer) in each tube. After 30 minutes at room temperature in the dark, the reaction was stopped by addition of 1000 microliter of 0.5N sulfuric acid. The absorbance was noted immediately by a photometer (at 492 nm).
RESULTS StUdy patients. Fifty of 119 patients studied were found to have paranasal sinus mycoses: 31 of these patients had noninvasive granuloma, 17 had invasive variety, and only two patients had recurrent sinusitis, microscopic presence of degenerated eosinophilia, interspersed segmented hyphae, but no tissue invasion. Most of these patients (70%) were in the 10- to 39year-old age group (Table 1) and a male preponderance was noted (M:F = 2.8: I). The patients came more from rural (34) than from urban areas (16). Twentyeight of these patients presented the lesion for the first time and the rest had recurrent infections. A majority of the patients in the invasive group (12 of 17) had infiltration already either in orbit or intracranially during their first visit to the hospital. Sinuses Involved. Amongst the different paranasal sinuses, fungal infections were noted commonly in ethmoid (42 patients) and maxillary sinuses (28 patients) (Table 2). Within the invasive variety, sphenoid (8 patients) and frontal sinuses (3 patients) are also commonly infected sites. In general, there was preponderance of right-sided sinus involvement. In invasive variety, the extension to orbit only was noted in II patients and intracranial extension only in two patients. Both orbital and intracranial extension were observed in four patients. Fungi responsible. In both noninvasive or invasive variety, different species of Aspergillus (A. flavus, 40; A. fumigatus, 3; Aspergillus spp, 2) were the most common isolates, followed by Alternaria species in two patients, Rhizopus arrhizus in two, and Candida albicans in one patient (Table 3).
Fungal Serology Noninvasive. Among the patients in whom Aspergilli were the etiologic agents (29 cases), the precipitins against different species of Aspergillus were detected in 28 (96.4%). Precipitins were absent in two patients in whom Alternaria species was isolated (Table 4). In six patients, when serology was repeated 2 to 3 weeks after the removal of the granuloma mass, precipitins were either absent or diminished in intensity or dilution (Table 5). In one patient it reappeared after one year, when symptoms and signs recurred. Invasive variety. In nine of 14 patients (64.3%) in whom Aspergilli were isolated, antibody against Asepergilli could also be demonstrated by gel diffusion. Precipitin against candida could be detected when Candida albicans was the responsible fungus. Patients in whom Rhizopus arrhizus was isolated were negatiye for precipitins against the antigens tested (Table 4). When serial recording of precipitin was performed in six patients, it was observed that either precipitins
Volume 107 Number 6 Part 1 December 1992
Epidemiology and pathogenesis of paranasal sinus mycoses
747
Table 1. Distribution of paranasal sinus mycoses by age and sex Age In years
In a prospective study, 50 cases of paranasal sinus mycoses were diagnosed In 2 years out of 119 clinically suspected patients from north India. Young men from rural areas were most commonly afflicted. Patients with paranasal sinus mycoses could be grouped In three clinical varieties: noninvasive. 31; Invasive, 17; allergic, 2. Maxillary and ethmoid were the common sinuses concurrently Involved In these patients, whereas sphenoid and frontal sinuses were also affected In Invasive variety. Aspergillus flavus (80%) was the most common Isolate. followed by A. fumlgatus (6%). Alternaria species was Identified In two patients with noninvasive granuloma. In Invasive variety. Rhlzopus arrhlzus and Candida alblcans were the causative agents In two patients and one patient, respectively. Regarding pathogenesis besides epidemiologic factors, the trnmunologlc factors were also evaluated. It was found that presence or absence of precipitating antibody against antigens from the etiologic agents correlates well with disease progression. Allergic factor was found In all varieties. though presence of cellmediated Immunity was demonstrated In 29% patients with noninvasive granuloma only. The combination of skin test against aspergillin and precipitin demonstration at the outset will therefore help In preliminary ·screenlng. (OTOlARYNGOL HEAD NECK SURG 1992;107:745.)
P
aranasal sinus mycoses was first reported by Mackenzie' in 1893. Since then. numerous cases were reported from different parts of the world, with higher incidence in the Sudan area.':' Although it is a rare entity in major parts of India-probably as a result of lack of awareness-it is not uncommon in north India.v' Different species of AspergilIus are the causative agents of this entity, with occasional case reports of other fungal involvement.?" The clinical spectrum and pathogenesis of this entity is not clear as yet, but the available data reveal several forms of paranasal mycoses, like noninvasive, invasive, fulminant, and alIergic types. Invasive and fulminant varieties are common in immunocompromised individuals,?" whereas the noninvasive type is more frequently encountered in the nonimmunocompromised hosts." The alIergic form mimics alIergic bronchopulmonary aspergilIosis. '2 In regard to development and progression of the disease, several factors like immu-
From the Department of Medical Microbiology. and ENT. Postgraduate institute of Medical Education and Research. Received for publication May 7, 1992; revision received Aug. 21. 1992; accepted Aug 24. 1992. Reprint requests: Arunaloke Chakrabarti, MD. Department of Medical Microbiology. Postgraduate Institute of Medical Education and Research. Chandigarh-160012. India.
23/1/42364
nologic status," site," duration,":" and presence of alIergyl2,'4 may playa role. Keeping the above facts in consideration, we prospectively evaluated all patients attending our Institute suspected to have paranasal sinus mycoses for 2 years (1990 and 91) to illustrate further the epidemiology and pathogenesis of this entity.
METHODS AND MATERIAL Study population. One hundred nineteen consecutive patients (109 with paranasal sinus granuloma and 10 with chronic maxillary sinusitis) were studied between January 1990 to December 1991. Detailed clinical history and informed consents were taken from these patients. The patients could be characterized into three groups on the basis of clinical features and radiologic findings: I. Patients with symptoms of unilateral/bilateral nasal obstruction, pressure feelings, and nasal discharge with or without nasal polyp (noninvasive variety, 92). 2. Patients with symptoms initialIy confined to one or multiple sinuses and later extended to the orbit or intracranially by means of bone erosion (invasive variety, 17). 3. Patients with symptoms of recurrent sinusitis along with history of asthma (allergic variety, 10). Microbiologic monitoring. Biopsy samples from patients with granuloma and antral wash from patients 745
746
OtolaryngologyHead and Neck Surgery
CHAKRABARTI et 01.
with sinusitis were processed in the microbiology laboratory following standard techniques.":" Direct microscopy in 10% potassium hydroxide and histopathology were performed for demonstration of fungal elements in tissue. All specimens were cultured by inoculation on Sabouraud's dextrose agar for growth of fungi. Different fungal isolates were identified by lactophenol cotton blue mount, slide culture in case of mycelial fungi, and by biochemical tests for yeast
species.":" Patients who were positive for paranasal sinus mycoses and twenty more patients with paranasal sinus granuloma who were negative for fungus etiology (control) were evaluated further by serology and skin test. Serology. Precipitin: Serum samples were collected from control and infected patients. Sera were tested for precipitin by Ochterlony's" gel diffusion techniques, using metabolic antigen of Aspergillus fumigatus, A. fiavus and A. niger. and cytoplasmic protein antigen of Candida albicans prepared according to Longbottom and Peppys" and Syverson et al.," respectively. Eleven antigens were prepared from three species of Aspergillus, using different strains within species isolated from patients with Aspergillosis. All antigens were checked for C-reactive substance before use. In 12 patients (six each with noninvasive and invasive variety) serial testing of sera were performed 2 to 3 weeks after surgery and whenever the symptoms or signs recurred after removal of granuloma mass. Skin test. Intradermal skin tests were performed using 0.1 ml of antigen (1000 PNU / ml Aspergillin, Hollister-Steir, USA) in all patients and controls. Types I (erythema, wheal within I hour) and IV (induration of more than 5 mm diameter after 24 hours) were noted in each case. Total IgE. Enzygnost-IgE monoclonal (Behring) kit was used for demonstration of total IgE after a sandwich enzyme immunoassay procedure. In tubes coated with mouse monoclonal anti-human IgE 20 microliter of test serum (each in duplicate) and 200 microliter of peroxide conjugated mouse monoclonal anti-human IgE were added simultaneously. Positive (300 IU / ml of IgE) and negative controls, each in duplicate, were put with each set of test. After incubation at 37° C for 1 hour, the tubes were washed three times with 2 ml of diluted washing solution (phosphate buffer containing Tween20, supplied with kit), followed by addition of 200 microliter of chromogen (O-phenylenediamine hydrochloride) and buffer-substrate (hydrogen peroxide 0.3 gL -I in citrate buffer) in each tube. After 30 minutes at room temperature in the dark, the reaction was stopped by addition of 1000 microliter of 0.5N sulfuric acid. The absorbance was noted immediately by a photometer (at 492 nm).
RESULTS StUdy patients. Fifty of 119 patients studied were found to have paranasal sinus mycoses: 31 of these patients had noninvasive granuloma, 17 had invasive variety, and only two patients had recurrent sinusitis, microscopic presence of degenerated eosinophilia, interspersed segmented hyphae, but no tissue invasion. Most of these patients (70%) were in the 10- to 39year-old age group (Table 1) and a male preponderance was noted (M:F = 2.8: I). The patients came more from rural (34) than from urban areas (16). Twentyeight of these patients presented the lesion for the first time and the rest had recurrent infections. A majority of the patients in the invasive group (12 of 17) had infiltration already either in orbit or intracranially during their first visit to the hospital. Sinuses Involved. Amongst the different paranasal sinuses, fungal infections were noted commonly in ethmoid (42 patients) and maxillary sinuses (28 patients) (Table 2). Within the invasive variety, sphenoid (8 patients) and frontal sinuses (3 patients) are also commonly infected sites. In general, there was preponderance of right-sided sinus involvement. In invasive variety, the extension to orbit only was noted in II patients and intracranial extension only in two patients. Both orbital and intracranial extension were observed in four patients. Fungi responsible. In both noninvasive or invasive variety, different species of Aspergillus (A. flavus, 40; A. fumigatus, 3; Aspergillus spp, 2) were the most common isolates, followed by Alternaria species in two patients, Rhizopus arrhizus in two, and Candida albicans in one patient (Table 3).
Fungal Serology Noninvasive. Among the patients in whom Aspergilli were the etiologic agents (29 cases), the precipitins against different species of Aspergillus were detected in 28 (96.4%). Precipitins were absent in two patients in whom Alternaria species was isolated (Table 4). In six patients, when serology was repeated 2 to 3 weeks after the removal of the granuloma mass, precipitins were either absent or diminished in intensity or dilution (Table 5). In one patient it reappeared after one year, when symptoms and signs recurred. Invasive variety. In nine of 14 patients (64.3%) in whom Aspergilli were isolated, antibody against Asepergilli could also be demonstrated by gel diffusion. Precipitin against candida could be detected when Candida albicans was the responsible fungus. Patients in whom Rhizopus arrhizus was isolated were negatiye for precipitins against the antigens tested (Table 4). When serial recording of precipitin was performed in six patients, it was observed that either precipitins
Volume 107 Number 6 Part 1 December 1992
Epidemiology and pathogenesis of paranasal sinus mycoses
747
Table 1. Distribution of paranasal sinus mycoses by age and sex Age In years
