Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis,☆☆,,★★,

https://doi.org/10.1016/S0091-6749(98)70125-3Get rights and content

Abstract

Background: Few cases of allergic fungal sinusitis have been systematically evaluated to conclusively confirm working clinical, histopathologic, and serologic diagnostic criteria.

Objectives: The objective of this study was to describe 67 consecutive cases of allergic fungal sinusitis, the largest number of cases yet published.

Methods: Cases from 1 practice over 8 years were evaluated with a consistent protocol, including skin testing, serum chemistries and serologies, and surgical specimen analysis.

Results: All patients were atopic (100%) and had nasal polyposis (100%). They tended to be young (33.3 ± 13.1 years, mean ± SEM), immunocompetent (92%; remaining 8% with low quantitative immunoglobulin but normal function), have slight female preponderance (58%), have a history of hypertrophic rhinosinusitis (100%), report nasal cast production (75%), and have developed their disease in the southwestern United States. Bipolaris spicifera was the most prevalent fungus involved (67%). Total serum IgE (mean 668 IU/mL) and fungal-specific IgG were generally elevated, whereas fungal-specific precipitins and specific IgE were generally negative despite positive fungal-specific immediate hypersensitivity skin tests.

Conclusions: Patients with allergic fungal sinusitis tend to have elevated total serum IgE and fungal-specific IgG at diagnosis but not fungal-specific IgE or precipitins. Histopathologic criteria for allergic fungal sinusitis diagnosis are discussed. The southwestern United States appears to be a “hot spot” for the disease, particularly caused by B spicifera. (J Allergy Clin Immunol 1998;102:387-94.)

Section snippets

METHODS

Patients with AFS were either referred perioperatively by various otolaryngologic surgeons or were diagnosed during the course of medical management for allergic respiratory disease. All patients suspected of having AFS therefore had undergone the study—entering sinus surgery just before or early during the course of our initial evaluation. The diagnosis of AFS was made in 67 consecutive patients over 8 years from 1 Allergy and Immunology practice (M.S.S.), and each had been subsequently

RESULTS

Sixty-seven patients with AFS initially were seen, as described in the Methods section. Four histopathologic criteria for the diagnosis of AFS are described in Table I; all criteria had to be met for the diagnosis of AFS. First, allergic mucin from the sinus surgery specimen was present either microscopically on the H&E stain, on gross inspection at surgery, or both. Second, either a positive silver stain for fungal hyphae was manifested in the allergic mucin and/or the surgical fungal culture

DISCUSSION

AFS is increasingly being recognized as a complicating feature of hypertrophic rhinosinusitis. Although other cases of fungal sinusitis have been reported, consistent differentiation of AFS from all other forms of fungal sinusitis has only recently been scrutinized.

Our large database of 67 consecutive patients has allowed a more thorough demographic and diagnostic analysis of AFS than has previously been published. Several conclusions can be drawn from the current clinical series. Patients with

Acknowledgements

We wish to acknowledge the assistance and laboratory skills of Bonnie Whisman, MS, and Mary Fust, LPN. We thank Peter Nutley, MD, Joseph Spataro, MD, Michael Reid, MD, and Edward Chu, MD, for helpful discussions and the staff of the Allergy Asthma Clinic.

References (38)

  • WD Travis et al.

    Unusual aspects of allergic bronchopulmonary fungal disease: report of two cases due to Curvularia organisms associated with allergic fungal sinusitis

    Hum Pathol

    (1991)
  • DS Gourley et al.

    Allergic Bipolaris sinusitis: clinical and immunopathologic characteristics

    J Allergy Clin Immunol

    (1990)
  • SC Manning et al.

    Evidence of IgE-mediated hypersensitivity in allergic fungal sinusitis

    Laryngoscope

    (1993)
  • JP Bent et al.

    Diagnosis of allergic fungal sinusitis

    Otolaryngol Head Neck Surg

    (1994)
  • JE Waxman et al.

    Allergic Aspergillus sinusitis: concepts in diagnosis and treatment of a new clinical entity

    Laryngoscope

    (1987)
  • GM Wickern

    Pediatric allergic fungal sinusitis: another “great masquerader.”

    Pediatr Asthma Allergy Immunol

    (1993)
  • KJ Daghistani et al.

    Allergic aspergillus sinusitis with proptosis

    J Laryngol Otol

    (1992)
  • WM Lydiatt et al.

    Allergic fungal sinusitis with intracranial extension and frontal lobe symptoms: a case report

    Ear Nose Throat J

    (1994)
  • WJ Chang et al.

    Bilateral orbital involvement with massive allergic fungal sinusitis

    Arch Ophthalmol

    (1996)
  • Cited by (172)

    • Fungal sinusitis

      2017, Revue des Maladies Respiratoires
    • Sinusitis

      2016, Pediatric Allergy: Principles and Practice: Third Edition
    • Allergic Fungal Rhinosinusitis

      2016, Journal of Allergy and Clinical Immunology: In Practice
    View all citing articles on Scopus

    From athe Allergy Asthma Clinic, Phoenix; and bthe Department of Allergy-Immunology, Wilford Hall Medical Center, Lackland AFB.

    ☆☆

    Supported in part by the US Air Force.

    The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other Departments of the US Government.

    ★★

    Reprint requests: Mark S. Schubert, MD, PhD, Allergy Asthma Clinic, 31 W Camelback Road, Phoenix, AZ 85013.

    1/1/91757

    View full text