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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 103-106

Study of fungal rhinosinusitis


Department of Pathology, GMC, Guntur, Andhra Pradesh, India

Date of Submission26-Jun-2020
Date of Acceptance28-Jun-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Padmavathi Devi Chaganti
Department of Pathology, Guntur Medical College, Guntur, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_98_20

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  Abstract 


Background: Rhinosinusitis is a common disorder occurring in 20% of the population. Chronic sinus infection unresponsive to antibiotics should raise the suspicion of Fungal rhinosinusitis. Various types of fungi caused inflammation of sinus mucosa.
Aims and Objectives: Thepresent studywas undertakento determine the etiology, clinical features, and diagnosis of Fungal Rhinosinusitis.
Material and Methods: Twenty cases of rhinosinusitiswere studied in two years period in a tertiary care hospital. Specimens collected were processed with paraffin processing andstained with H and E stain. Special stains for Fungus were done in all cases.
Results: Cases of Rhinosinusitis were mostly seen in the 5th decade with femalepreponderance. All the cases were non-invasive and Maxillary sinus was involved in majority of cases. Aspergillus was identified in majority of cases followed by Candida. Mucor mycosis was seen in diabetics.
Conclusion: In the present study, all the cases of rhinosinusitis are non-invasive. A special stain for Fungus helps in identifying the type of organism.

Keywords: Aspergillus, candida, fungus, mucor


How to cite this article:
Chaganti PD, Rao NB, Devi KM, Janani B, Vihar PV, Neelima G. Study of fungal rhinosinusitis. J NTR Univ Health Sci 2020;9:103-6

How to cite this URL:
Chaganti PD, Rao NB, Devi KM, Janani B, Vihar PV, Neelima G. Study of fungal rhinosinusitis. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Aug 5];9:103-6. Available from: http://www.jdrntruhs.org/text.asp?2020/9/2/103/289901




  Introduction Top


Rhinosinusitis is a common disorder occurring in 20% of the population.[1] Several etiological factors are proposed as causative factors. Symptoms of chronic sinus infection unresponsive to antibiotics should raise the suspicion of Fungal rhinosinusitis.[2] Inflammation of sinus mucosa is caused by Fungi like Aspergillus, Candida, mucormycosis, scedosporium, and penicillium.[3] Fungal Rhino Sinusitis is divided into Non-invasive and invasive forms. Non-invasive forms include Allergic fungal rhinosinusitisand fungal ball. The invasive form included acute invasive, chronic invasive, and Granulomatous forms: radiological examination and diagnostic endoscopy help in suspecting the disorder.[4] Histopathological examination, including special stains for Fungus, helps in confirming the diagnosis.


  Materials and Method Top


This was a prospective study of 20 patients with rhinosinusitis who underwent treatment in our institution from 2017 to 2019. In all the cases, Radiography and computer tomography imaging of the nose and paranasal sinuses weredone. All the patients underwent diagnostic nasal endoscopy, and the specimen was obtained for pathological examination. The specimens were fixed in 10% buffered formalin and processed with routine paraffin processing and Stained with H and E stain. Special stains done for the identification of Fungus were Gomori methenamine silver stain [GMS] and periodic acid Schiff stain [PAS]. Permission from ethical committee with IECNo application no GMC/IEC?206/2019 was approved.


  Results Top


Twenty casesdiagnosed as rhinosinusitis were studied in a two-year period. The majority of cases belonged tothe 5th decade of life. All cases were seen in females. The most common clinical symptom was nasal obstruction, followed by nasal discharge. There was ahistory of diabetes mellitus in fourcases. Nine out of 20 cases showed involvement of Maxillary sinus followed bythe involvement of Ethmoidal sinus in four cases, seven cases presented with nasal polyps. Radiological findings showed heterogenous sinus opacity, with or without pseudocalcification [Figure 1].
Figure 1: Ct Scan nose and paranasal sinuses showing hyper dense lesion in maxillary and sphenoid sinuses

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Microscopically, the Nasal polyps were lined by respiratory epitheliumwith squamous metaplasia. Stroma showed myxoid matrix surrounding mucous glands and infiltrated by lymphocytes, plasma cells, neutrophils, and eosinophils [Figure 1].

In our study, there were 11 cases of aspergillus infection (55%), followed by candidiasis in five cases (25%). Mucormycosis constitutedthe least number and were seen in four cases (20%). And there was an association of diabetes mellitus in all the four cases of mucormycosis. In a single case of candidiasis, there was a fungal ball. Fungi might not be identified on routine H and E staining. PAS and GMS confirm types of fungi. In one case of Aspergillus, there were fruiting bodies.

PAS stain and GMS confirmed the type of Fungus.

Aspergillus infection showed uniform, narrow septate hyphae about 2 to 4 microns that branch at acute angles, also called as dichotomous branching [Figure 2].[5] Conidiospores are also seen forming fruiting bodies [Figure 3].
Figure 2: GMS stain [100 × and Inset 450×] aspergillus with acute angle branching with septations

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Figure 3: H and E and GMS Stain [100×] fruiting bodies of aspergillus

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Candida was identified as budding yeasts 2 to 6 microns in diameter. Mycelial elements show pseudohyphae. Histologically in the fungal ball, there were dense collections of fungal hyphae [Figure 4].
Figure 4: H and E [100 × and Inset 450×] and GMS Stain [100×] candida showing pseudo hyphae-fungal ball

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Mucormycosis was diagnosed by broad hyphae measuring 5 to 20 microns with right-angled branching [Figure 5] and [Figure 6]. Mucor Mycosis could be identified on routine H and E stain, in majority of cases there were areas of necrosis.
Figure 5: H and E Stain [100 × And Inset 450×] mucor mycosis showing broad aseptate thin walled right angled branching hyphae

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Figure 6: GMS Stain [100 × And Inset 450×] mucor mycosis

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  Discussion Top


Fungal Rhinosinusitis is classified into non-invasive rhinosinusitis, and invasive fungal rhinosinusitis.[4] Non-invasive fungal rhinosinusitis constitutes fungal colonization, fungal ball, and allergic fungal rhinosinusitis (AFRS).[4] Invasive fungal rhinosinusitis is again divided into acute invasive, chronic invasive, and chronic granulomatous forms.[4] In the present study, all our cases belonged to non-invasive fungal rhinosinusitis. According to Hardik shah, among fungal rhinosinusitis, 48% were non-invasive fungal rhinosinusitis, and 52% were invasive fungal rhinosinusitis. Among non-invasive fungal rhinosinusitis, allergic rhinosinusitis constitutes 72.91% of cases, remaining being fungal balls.[1] Allergic fungal rhinosinusitis (AFRS) develops in patients with recurrent nasal polyps and asthma. The diagnosis of AFRS was made when there were nasal polyps, fungi on staining, eosinophilic mucus without fungal invasion into sinus tissue, type I hypersensitivity to fungi, and characteristic radiological findings on CT scan.[6] Type 1 hypersensitive reaction is determined by skin prick or radioallergosorbent.[4] Nasal polyps with eosinophilic mucus were seen in 7 casesin our study. We could not demonstrate Type 1 Hypersensitivity as the facilities were not available. Nasal polyps were formed in association with inflammation or allergy. Accumulation of fungal elements within a single sinus constitutes a fungal ball. Maxillary sinus was the most common sinus involved in a fungal ball. In our study, a single case of fungal balls was seen in a female patient inMaxillary sinus. Fungal balls were more common in women who were middle-aged, and histologicallyAspergillus was the most common Fungus.[4] In a single case of Fungal ball in our study Aspergillus was identified. The most common age group for fungal rhinosinusitis was 19 to 43 years with Male preponderance.[3] In our study, there was Female preponderance and were seen in the 5th decade. The commonest clinical symptom, according to Jyothika Wagharay et al., was Nasal obstruction, Facial swelling, followed by postnasal drip and facial pain.[2] In our study, the commonest symptom was nasal obstruction. History of Diabetes mellitusindicating immunocompromised state was most commonly associated with the invasive form, In our study, all four cases of mucormycosis had a history of Diabetes mellitus, and all cases were non-invasive. Maxillary sinus was most commonly involved, followed by ethmoid and sphenoidal sinus.[2] According toHardik, shah et al. Aspergillus was the most common fungal infection.[1] According to Sandeep Suresh et al., Candida was the most common organism, followed by Mucor.[2] In the present study also Aspergillus constitute 55% of cases. Mucor was the most common organism identified in routine histology.

The histopathological examination shows lining by respiratory epithelium showing features of squamous metaplasia. Polyps are infiltrated by lymphoplasmacytic infiltrates.[5] Our study showed features consistent with the above features. Polyps were associated with Aspergillus in most of the cases. In our study also polyps showed associated aspergillus infection.

Aspergillus shows branching septate fungi with branching at acute angles along with chronic inflammation. Conidiospores forming fruiting bodies are also seen.[7] Similarmicroscopic features were observed in our study.

Dense collections of fungal elements in a single sinus are known as the fungal ball. Maxillary sinus wasthe most commonly involved sinus constituting 84%. Microscopy shows concretions composed of dense collections of fungal hyphae. Aspergillus is the most common Fungus forming fungal ball.[4] The single case of the fungal ball in our study showed features of candidiasis. Candida shows budding yeasts with pseudohyphal forms.[2] In our study also both pseudo and true hyphal forms were seen.

According to Sandeep Suresh et al., Mucor was identified by right angle aseptate hyphae.[2] Our study also shows consistent features.


  Summary and Conclusion Top


Fungal rhinosinusitis comprises a wide spectrum of diseases ranging from non-invasive and invasive fungal forms. The non-invasive form includes AFRS and fungal ball. In the present study, all the cases were non-invasive fungal RhinoSinusitis.

Cases of Fungal infections require special stains PAS And GMS to demonstrate the type of Fungus. Mucor could be identified on routine H and E stain. The most common clinical feature in all cases was nasal obstruction. Aspergillus was the most common Fungus, followed by Candida. Fungal balls and Fruiting bodies were seen in aspergillus infection. Four cases of Mucor Mycosis showed association with Diabetes, suggesting immune suppression.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shah H, Bhalodiya N. Scenario of fungal infection of nasal cavity and paranasal sinuses in Gujarat: A Retrospective Study. GMJ 2014;69:27-31.  Back to cited text no. 1
    
2.
Suresh S, Arumugam D, Zacharias G, Palaninathan S, Vishwanathan R, Venkatraman V. Prevalence and clinical profile of fungal rhinosinusitis. Allergy Rhino 2016;7:115-20.  Back to cited text no. 2
    
3.
Waghray J. Clinical study of fungal sinusitis. J Int J Otorhinolaryngol Head Neck Surg 2018;4:1307-12.  Back to cited text no. 3
    
4.
Zachary M, Soler MD, Schlosser RJ. The role of fungi in disease of the nose and sinuses. J Rhinol Allergy 2012;26:351-8.  Back to cited text no. 4
    
5.
McHugh JB. Upper Aerodigestive Tract, Rosai, and Ackermans Surgical Pathology. 11 ed. 2018. p. 165.  Back to cited text no. 5
    
6.
Bent JP, Kuhn FA. Diagnosis of allergic fungal rhinosinusitis. Otolaryngol Head Neck Surg 1994;111:580-8.  Back to cited text no. 6
    
7.
Tamgadge AP, Mengi R, Tamgadge S, Bhalerao SS. Chronic invasive aspergillosis of paranasal sinuses: A case report with review of literature. J Oral Maxillofac Pathol 2012;16:460-4.  Back to cited text no. 7
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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