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Fungal Sinusitis

 

  • Most commonly occurs in immunocompromised pts (hematologic malignancies, BMT, solid organ transplant recipients, chemo-induced neutropenia, advanced HIV, DM)
  • Immunosuppression is also the major risk factor for invasive fungal infections outside of the sinuses
  • Clinical presentation is acutely with fever, facial pain, nasal congestion, epistaxis, and changes in vision or mental status.
  • Facial numbness or diplopia may occur in the setting of CN involvement. (many patients already have extension of the infection outside the sinuses at the time of presentation)
  • CT shows sinus involvement, and may reveal bony erosions; however, none of the CT findings are specific enough to allow for a diagnosis. MRI should be performed to assess intracranial and cavernous sinus involvement (especially in patients with focal neurologic deficits
  • Most common species are mucor, rhizopus and aspergillus (Candida less commonly and less virulent) 
  • Normal hosts can be colonized with fungal spores (especially aspergillous), but not clinically infected
  • Treatment is primarily emergency surgical debridement and, if possible, correction of the underlying immunologic derangement. Secondary treatment includes systemic anti-fungal therapy.
  • Despite timely surgical debridement, and appropriate adjuvant medical treatment, mortality rates remain upwards of 50 percent

 

 

Overview of antifungal agents:

 

Ampho B

Azoles

Echinocandins

Candida spp

S

S (except C. krusei; C. glabrata has reduced susceptibility)

S

Aspergillous

S (except A. terreus)

S (not fluconazole, vori is first line)

S (but only in combo tx)

Scedosporium

R

S (not fluconazole)

R

Zygomycoses (mucor, rhizopus, Cunninghamella)

S

R (except posaconazole, but not first line tx, since it is only po)

R

 

 

(Victoria Kelly MD, 12/20/10)