|Year : 2013 | Volume
| Issue : 3 | Page : 266-269
Fungal rhinosinusitis: A prospective study in a University hospital of Uttar Pradesh
S Prateek1, G Banerjee1, P Gupta1, M Singh1, MM Goel2, V Verma3
1 Department of Microbiology, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of Pathology, King George Medical University, Lucknow, Uttar Pradesh, India
3 Department of ENT, King George Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||04-Mar-2013|
|Date of Acceptance||24-May-2013|
|Date of Web Publication||25-Jul-2013|
Department of Microbiology, King George Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: To assess the purpose of fungal rhinosinusitis in a University hospital and to correlate histopathological findings with culture results for accurate clinical classification of the disease. Materials and Methods: One-hundred suspected patients were included in the study. Data was collected in a brief predetermined format. Samples like nasal lavages, sinus secretions, and tissue specimens were processed and examined by microbiology culture using recommended techniques. Slide culture was done to observe the microscopic morphology. Histopathological examination was done by H and E stain and PAS stain for classification. Results: Out of 100 cases of rhinosinusitis, 21 cases were culture-positive for fungal rhinosinusitis. On the basis of histopathological findings, 14 cases (66.67%) were found to be of non-invasive fungal rhinosinusitis. Aspergillus flavus was the most common fungal isolate. Conclusion: Mycological profile of rhinosinusitis in Lucknow was thus evaluated. Histopathological and microbiological findings reported 21 cases of fungal rhinosinusitis among 100 suspected cases of rhinosinusitis.
Keywords: Aspergillus flavus, chronic rhinosinusitis, fungal rhinosinusitis, PAS and H and E stain
|How to cite this article:|
Prateek S, Banerjee G, Gupta P, Singh M, Goel M M, Verma V. Fungal rhinosinusitis: A prospective study in a University hospital of Uttar Pradesh. Indian J Med Microbiol 2013;31:266-9
|How to cite this URL:|
Prateek S, Banerjee G, Gupta P, Singh M, Goel M M, Verma V. Fungal rhinosinusitis: A prospective study in a University hospital of Uttar Pradesh. Indian J Med Microbiol [serial online] 2013 [cited 2020 Feb 19];31:266-9. Available from: http://www.ijmm.org/text.asp?2013/31/3/266/115634
| ~ Introduction|| |
Traditionally, fungal infections of paranasal sinuses have been considered uncommon and were thought to occur only in immunocompromised individuals. However, its incidence in recent years has shown a marked increase in immunocompetent population, especially in Northern Sudan, in South-eastern states of USA and in North India.  It significantly impacts quality of life in comparison to chronic debilitating diseases such as diabetes and congestive heart failure.  Sinusitis or more accurately rhinosinusitis is a common disorder affecting 20% of the population.  Rhinosinusitis occurs in both acute and chronic forms, and represents a potential heterogeneity of pathophysiologies and prognosis. Chronic rhinosinusitis accounts for more than 90% of all cases of rhinosinusitis, has a slow protracted course, and has different aetiologies, fungal infections being a major cause. 
Fungal rhinosinusitis is a common disorder in India, but no population-based data is available. The commonest category appears to be allergic fungal rhinosinusitis and Aspergillus flavus being the most common etiological agent without any apparent strain clustering. More studies are needed to understand the Indian occurrence of fungal rhinosinusitis.
Diagnosis of fungal rhinosinusitis is based on high index of clinical suspicion, because clinical history and physical examination of the patient per se are rarely conclusive. Clinical presentation can provide a clue to the subcategories of fungal rhinosinusitis; however, the diagnosis depends upon direct microscopic examination, culture and histopathology of the tissue or the cheesy material obtained from the sinuses. Histopathology is important to distinguish the invasive from the non-invasive type and classify the disease. Direct microscopy and culture helps in establishing the aetiology. 
Hence, a detailed examination along with correlation with culture results is necessary. Early diagnosis and accurate classification of fungal rhinosinusitis may help in deciding the treatment protocol and preventing multiple surgical procedures and lead to effective treatment. Clarification of classification of fungal rhinosinusitis and the criteria for their diagnosis should facilitate clinical trials necessary to establish appropriate treatment. 
The aim of this study was to determine the prevalence of fungal rhinosinusitis and determine accurate classification and establish the aetiology so as to estimate the disease burden in the area and help in determining further treatment protocol.
| ~ Materials and Methods|| |
The study was planned as a prospective observational study. One-hundred suspected patients were included in the study, agreed by verbal consent to participate in the study. Data was included in a predesigned format. It included patient's identification number, name, age, sex, patient's history, clinical presentation, radiological findings, microbiological results and histopathological diagnosis. Clinical assessment was done.
Samples collected included nasal lavages, nasal secretions and tissue specimens. The tissue specimens were collected from the sinuses by endoscopic sinus surgery. A portion of surgically excised specimen was received in sterile container containing normal saline to mycology laboratory, and another part of the specimen was received in a sterile container containing 10% formalin in the histopathology laboratory for final histopathological diagnosis.
The tissue specimens received in the mycology laboratory were minced into small pieces (0.5-1 mm in diameter) using sterile scalpel, pestle and mortar. The specimens were examined direct microscopy and culture using recommended techniques in Evans Book of Mycology.  Direct 20% KOH mount preparation was made of the specimen and examined. Culture was done on Sabouraud's dextrose agar with Chloramphenicol and incubated at 25 0 C and 37 0 C, respectively. Further identification of fungal isolates was done by procedures recommended in the standard mycology textbooks by Evans and Larone. ,
Histopathological examination of the specimen was done by Haematoxylin and Eosin stain and Periodic Acid Schiff stain.
| ~ Results|| |
Out of 100 cases of rhinosinusitis, 21 cases were culture-positive for fungal rhinosinusitis. Maximum number of cases were found to be of the age group 31-40 years (42.86%), followed by 41-50 years (28.57%) and 21-30 years (19.05%). Male:Female ratio was approximately 1.33:1. Most of the confirmed cases were found to be in the lower socio-economic status (71.43%). Thirteen (62%) confirmed cases of fungal rhinosinusitis were found to be from urban areas as compared to 8 (38%) cases coming from the rural areas [Table 1].
|Table 1: Distribution of fungal isolates identified among cases of fungal rhinosinusitis |
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The most common presentations in cases of fungal rhinosinusitis were nasal obstruction (100%) and nasal discharge (100%) followed by headache (71.43%) and facial pain/swelling (57.14%) [Table 2], [Table 2], [Table 3].
|Table 2: Histopathological classification of cases of fungal rhinosinusitis |
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|Table 3: Distribution of fungal isolates among various histological types of fungal rhinosinusitis |
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Aspergillus spp. (76.19%) was the most common isolated species among all cases of fungal rhinosinusitis with Aspergillus flavus (57.14%) being the most common fungal isolate followed by Aspergillus fumigatus (14.29%).
On the basis of histopathological findings, 14 cases (66.67%) were found to be of non-invasive fungal rhinosinusitis. These included 12 cases (57.14%) of allergic fungal rhinosinusitis, and 2 cases (9.52%) of fungal ball. Seven cases (33.33%) were of invasive fungal rhinosinusitis, out of which 2 cases (9.52%) were of acute fulminant invasive fungal rhinosinusitis, 2 cases (9.52%) of granulomatous invasive fungal rhinosinusitis and 3 cases (14.29%) of chronic invasive fungal rhinosinusitis. Of all the cases of fungal rhinosinusitis, allergic fungal rhinosinusitis was the most common histopathological diagnosis.
Aspergillus flavus was the most common fungus, isolated in 8 cases (66.67%) of allergic fungal rhinosinusitis, of all the 12 cases of allergic fungal rhinosinusitis. In fungal ball, Aspergillus flavus was isolated in one case and Aspergillus fumigatus from the other case. Mucor spp. was the fungal species isolated in both the cases of acute fulminant invasive fungal rhinosinusitis. Aspergillus flavus was isolated in both the cases of granulomatous invasive fungal rhinosinusitis. In chronic invasive fungal rhinosinusitis, Aspergillus fumigatus was the most common aetiological agent identified, being isolated in 2 cases (66.67%) of the 3 cases of chronic invasive fungal rhinosinusitis.
| ~ Discussion|| |
Fungal rhinosinusitis, once considered a rare disorder, is now being recognized and reported with increasing frequency worldwide. In last 10 years, more than 200 cases had been reported in various studies.  One such study conducted by Das et al., 2007, at Chandigarh reported fungal rhinosinusitis with incidence of 42.7% of all the 665 cases of chronic rhinosinusitis over a period of 5 years.  The current study has, on the basis of clinical, histopathological, microbiological and radiological findings, reported 21 cases of fungal rhinosinusitis among 100 suspected cases of chronic rhinosinusitis over a period of one year.
In some but not all studies from Sudan and North India, fungal rhinosinusitis has been documented commonly in young adult males from rural areas than others.  A study conducted by Das et al., in Chandigarh, reported ages of the patients with fungal rhinosinusitis ranged from 2 to 81 years (mean-31 years). There was predominance of fungal rhinosinusitis in male patients with a Male:Female ratio of 1.8:1.  A study by Michael et al., 2007, conducted at Vellore reported fungal rhinosinusitis in patients with mean age of 45.7 years ranging from 11 to 79 years with male to female ratio 0.8:1.  There were more patients from rural areas than from urban areas in the same study.  In our study, the age of patients with fungal rhinosinusitis ranged from 22-63 years with 42.86% of patients in 3 rd decade of life followed by 4 th decade (28.57%) with mean age being 39 years and male to female ratio being 1.33:1. Sixty-two percent of patients belonged to urban area and 38% of patients belonged to rural areas with 71.43% of patients coming from low socio-economic background.
Panda et al., in their study, categorized 178 patients diagnosed as having paranasal sinus mycoses into three disease groups- Allergic (8), non-invasive (92) and invasive (78) on the basis of histopathological and mycological investigations.  In a prospective study of 176 cases of fungal rhinosinusitis, Chakrabarti et al. classified the patients into allergic (12 patients), non-invasive without bony destruction (81 patients), non-invasive destructive (16), chronic invasive (55) and fulminant (12).  We, in our study, on the basis of clinical, radiological, histopathological and mycological findings, classified 21 patients of fungal rhinosinusitis and following observations were made: 14 cases (66.67%) were of non-invasive fungal rhinosinusitis including 12 cases of allergic fungal rhinosinusitis (57.14%) and 2 cases of fungal ball (9.52%), whereas invasive fungal rhinosinusitis constituted of 7 cases (33.33%) including 2 cases of acute fulminant invasive fungal rhinosinusitis (9.52%), 2 cases of granulomatous invasive fungal rhinosinusitis (9.52%) and 3 cases of chronic invasive fungal rhinosinusitis (14.29%). Allergic fungal rhinosinusitis constituted of 12 cases (57.14%) of all the cases of fungal rhinosinusitis and was the most common histopathological diagnosis. 
In the initial studies, Aspergillus fumigatus was considered the primary aetiologic agent of AFRS cases, but later, pigment-producing dematiaceous fungi- Bipolaris spicifera, Exserohilum roibatum, Curvularia lunata and Alternaria spp. were found as predominant aetiologic agents in Western literature.  Data published from various studies from India differ from those reported in the western literature and state Aspergillus flavus as the predominant agent in cases of allergic fungal rhinosinusitis in the Indian sub-continent. A study by Saravanan et al., in Chandigarh, reported that among the 32 patients in the allergic fungal rhinosinusitis group, the most common culture isolate was Aspergillus flavus (81%), followed by Aspergillus fumigatus (9%). Bipolaris species was isolated in only 2 patients (6%).  In our study of all the 12 cases of allergic fungal rhinosinusitis, culture was positive in all the cases, whereas smear was negative in 3 cases. The results were correlated with the histopathological findings, and it was found that Aspergillus spp. was the most common fungus isolated in 8 cases (75%) of allergic fungal rhinosinusitis with Aspergillus flavus being the most common species isolated (66.67% of cases of allergic fungal rhinosinusitis). Phaeoid fungi were isolated in 3 cases (25%). In our study, histopathologically allergic fungal rhinosinusitis was diagnosed in 12 cases of all the 21 cases of fungal rhinosinusitis by H and E stain and PAS stain. Inflammatory infiltrates and allergic mucin were found in all 12 cases, whereas non-invasive fungal hyphae and eosinophillic infiltrate was observed in 10 cases (83.33%). 
Chakrabarti et al., in a prospective study, reported 12 cases of acute fulminant invasive fungal rhinosinusitis among 176 cases of fungal rhinosinusitis.  Of all the cases of fungal rhinosinusitis diagnosed in our study, 2 cases were diagnosed as acute fulminant invasive fungal rhinosinusitis on the basis of microbiological, histopathological and radiological findings. Mucor spp. was isolated in both the cases, and histopathologically both cases showed inflammatory infiltrates with fungal hyphae invading into the mucosa and sub-mucosa.
Das et al., in their retrospective study on cases of fungal rhinosinusitis over a period of 5 years in Chandigarh, reported 48 cases of granulomatous invasive fungal rhinosinusitis (16.9%) among 284 cases of fungal rhinosinusitis. In our study, granulomatous invasive fungal rhinosinusitis was reported in 2 cases based on histopathological findings of presence of fungal hyphae invading into the adjacent tissue and granuloma formation in both the cases. Both cases were caused by Aspergillus flavus as in accordance with previous studies. 
Michael et al., in a study done in South India, reported 21 cases (10%) of chronic invasive fungal rhinosinusitis among 211 cases of fungal rhinosinusitis diagnosed. Aspergillus flavus was the aetiological agent in 10 cases and Aspergillus fumigatus in 8 cases among all the 21 cases of chronic invasive fungal rhinosinusitis detected. In the current study, 3 cases of CIFS were reported on the basis of histopathological, microbiological, radiological and clinical findings. Aspergillus fumigatus was the aetiological agent in 2 cases and Aspergillus flavus was isolated in 1 case. 
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[Table 1], [Table 2], [Table 3]
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