From the Guidelines
Invasive fungal sinusitis presents with severe, rapidly progressing symptoms that require immediate medical attention, including fever, rhinorrhea, and diplopia, similar to those seen with acute bacterial rhinosinusitis (ABRS), as well as nasal congestion, thick discolored nasal discharge, headache, visual disturbances, facial swelling or numbness, and mental status changes. The symptoms of invasive fungal sinusitis can be nonspecific, but clinicians should maintain a high index of suspicion for this diagnosis in immunocompromised patients with symptoms of ARS, orbital symptoms, and/or headache 1. According to the most recent evidence, affected patients are typically immunocompromised and include patients with neutropenia, hematologic malignancies, poorly controlled diabetes, acquired immunodeficiency syndrome, and organ transplantation and patients on immunosuppressive therapy including systemic steroids and chemotherapy 1.
Key Symptoms
- Fever
- Rhinorrhea
- Diplopia
- Nasal congestion
- Thick discolored nasal discharge
- Headache
- Visual disturbances
- Facial swelling or numbness
- Mental status changes
Diagnosis and Treatment
Diagnosis typically requires imaging studies and tissue sampling, and treatment involves aggressive surgical debridement combined with systemic antifungal medications like amphotericin B or isavuconazole 1. Nasal endoscopy may demonstrate pale mucosa progressing to ulceration and necrosis, and definitive diagnosis is made on biopsy with the identification of invasive fungi in the sinonasal mucosa, vessels, and bone 1. Given the angioinvasive nature of the fungi, complications include thrombosis, dissection, and pseudoaneurysm formation of the intracranial arteries, thrombosis of the cavernous sinus, infarction, and hemorrhage 1.
Risk Factors
- Immunocompromised states (such as uncontrolled diabetes, chemotherapy, organ transplantation, or HIV/AIDS)
- Neutropenia
- Hematologic malignancies
- Poorly controlled diabetes
- Acquired immunodeficiency syndrome
- Organ transplantation
- Patients on immunosuppressive therapy including systemic steroids and chemotherapy Without prompt treatment, invasive fungal sinusitis can be life-threatening with mortality rates exceeding 50% 1.
From the Research
Symptoms of Invasive Fungal Sinusitis
The symptoms of invasive fungal sinusitis can vary, but common symptoms include:
- Facial pain [(2,3)]
- Vision change [(2,3)]
- Blindness 3
- The symptoms can progress rapidly, especially in immunocompromised patients [(4,2,5,3)]
Disease Progression
Invasive fungal sinusitis can progress to involve adjacent vessels and soft/hard tissues 2, and can lead to:
- Orbital involvement [(3,6)]
- Intracranial involvement [(5,3)]
- Skull base involvement 3
Patient Characteristics
Patients with invasive fungal sinusitis often have underlying conditions, such as:
Classification
Invasive fungal sinusitis can be classified into different types, including:
- Acute invasive fungal sinusitis (AIFS) [(2,5)]
- Chronic invasive fungal sinusitis (CIFS) [(5,3)]
- Intermediate invasive fungal sinusitis 3