New Developments in Allergic Fungal Rhinosinusitis Pathophysiology and Treatment

Abstract

Background Allergic fungal rhinosinusitis (AFRS) is an endotype of chronic rhinosinusitis (CRS) with nasal polyps characterized by eosinophilic mucin laden with fungal hyphae entrapped in expanded sinus cavities with an exaggerated hypersensitivity to fungal elements. The last decade has elucidated fungi-driven inflammatory pathways contributing to the pathophysiology of chronic inflammatory respiratory diseases. In addition, novel therapeutic biologic options have become available for CRS over the last several years. Objective To review the current literature examining AFRS, focusing on recent developments in our understanding of its pathophysiology and implications for treatment options. Methods Review article. Results Fungi-driven respiratory inflammation has been linked to fungal proteinases and toxin activity. In addition, AFRS patients demonstrate a local sinonasal immunodeficiency in antimicrobial peptides and hence limited antifungal activity, along with an exaggerated type 2 inflammatory response, highlighting a possible imbalanced type 1, type 2, and type 3 profile. The elucidation of these dysregulated molecular pathways has highlighted novel potential therapeutic targets. As such, the clinical management of AFRS, which once included surgery and extended courses of oral corticosteroids, is transitioning away from long courses of oral corticosteroids to incorporate novel delivery mechanisms of topical therapeutic targets and biologics for recalcitrant disease. Conclusion AFRS is an endotype of CRS with nasal polyps (CRSwNP) for which the molecular pathways leading to its inflammatory dysfunction are beginning to be illuminated. In addition to affecting treatment options, these understandings may shape necessary changes to diagnostic criteria and the extrapolated effects of environmental changes on AFRS. More critically, a better appreciation of fungi-driven inflammatory pathways may have implications for the understanding of broader CRS inflammation.

Sensitivity patterns to fungal allergens in the population of Vinnytsya region

“…The high levels of total immunoglobulin E (tIgE) found in the present study may be a good predictive marker of an allergic reaction in both adults (Cameron & Luo, 2023) and children (Lin et al, 2021), as the concentration of allergen-specific IgE correlates with the likelihood of symptoms (Mokhtar et al, 2023). In particular, the higher the level of tIgE, the higher the likelihood of clinical manifestations of sensitization to Alternaria (López Couso et al, 2021).…”

Allergic Fungal Otomastoiditis: A Case Report

“…The pathophysiology of AFOM is considered analogous to that of AFRS since AFOM and AFRS share similar histopathological features. Fungal antigens may stimulate a type I and/or type III immunological response with eosinophilia producing allergic sticky mucin [ 11 , 12 ]. AFOM is a rare disorder with only four cases reported previously [ 6 - 9 ].…”

“…Given the possible similarity of pathophysiologies between AFOM and AFRS, the fundamental methods of management applied to patients with AFRS appear reasonable to use for patients with AFOM [ 11 ]. Therapeutic options include surgery and pharmacotherapy.…”

Randomized Control Study to Analyse the Efficacy Budesonide Nasal Douching on Allergic Fungal Rhinosinusitis

“…Allergic fungal rhinosinusitis (AFRS) indeed stands out as a distinct entity among sinus diseases, characterized by its non-invasive nature and association with fungal antigens hypersensitivity{4,5}. Its unique clinical presentation, histopathological features, and radiological findings set it apart from other forms of sinusitis.…”