Perioperative Indicators of Prognosis in Acute Invasive Fungal Sinusitis

Abstract

Objective The purpose of this study is to identify perioperative independent prognostic factors that are available to the consulting team to aid in determining prognosis in patients with acute invasive fungal sinusitis. Study Design Retrospective chart review of patients with biopsy-proven acute invasive fungal sinusitis from 2015 to 2018. Setting Academic tertiary care center. Methods Twenty-one patients were included from our single-center retrospective review. Kaplan-Meier graphs were created, and the Breslow test used to compare the curves to obtain P values. A univariate Cox regression analysis was performed on the data that were significant at 3 months from diagnosis. Results Twenty-one patients were included, and 17 (76%) had an underlying hematologic malignancy. Overall survival was 71% and 52% at 1 and 3 months, respectively, and 94% of patients with hematologic malignancy had an absolute neutrophil count ≤1 at diagnosis. Absolute neutrophil count values and fungal species were not associated with a difference in prognosis. Factors associated with decreased survival included current smoking and the absence of a rhinologist on the treatment team at the initial or subsequent debridement (hazard ratio, 3.03). Laboratory values such as beta-D-glucan and galactomannan were assessed in addition to disease extension at diagnosis. Conclusion This study presents a retrospective review of a single institution’s experience with acute invasive fungal sinusitis. Subspecialty level of care likely improves overall survival in these patients, whereas current smoking may imply a worse prognosis.

Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence‐Based Review with Recommendations

“…Those not reporting this information typically utilized heterogeneous time intervals, such as days from neutropenia or bone marrow transplant until diagnosis or days from symptom onset to diagnosis or admission 14,23,33,41,48,50 . When timing of disease progression was reported, the disease course occurred over days to weeks, with a large fraction of disease‐related mortalities occurring within the first 4 weeks of symptoms 27,49,51,54 …”

“…Some report poor prognostic associations for Aspergillus spp 7 or so‐called “atypical” (non‐ Aspergillus spp/non‐mucormycete) molds, 5 although the latter has not been consistently reproduced 56 . Others have identified 57 or suggested poorer outcomes with mucormycosis 27,68 . Culture sensitivity may be decreased for mucormycetes and non‐ Aspergillus spp/non‐mucormycete molds 60,61,64 .…”

Risk Stratification of Acute Invasive Fungal Rhinosinusitis in Patients With Hematologic Pathology

“…With regards to AIFS, Aspergillus antigen has been identified as a specific marker in a setting of high clinical suspicion across multiple studies. B‐D‐Glucan (BDG), a polysaccharide cell wall component found in most fungal species, has not consistently shown to be sensitive or specific for AIFS; however, some studies have shown promise in utilizing serial testing of BDG to monitor treatment responses for some fungal disease processes 12–16 …”

“…B-D-Glucan (BDG), a polysaccharide cell wall component found in most fungal species, has not consistently shown to be sensitive or specific for AIFS; however, some studies have shown promise in utilizing serial testing of BDG to monitor treatment responses for some fungal disease processes. [12][13][14][15][16] This study sought to develop a novel scoring system that better represents the diagnostic probability of biopsy proven AIFS in suspected patients with an underlying hematologic malignancy. The results of this study corroborate previous evidence that commonly ordered ancillary tests provide objective markers for risk analysis in patients with hematologic malignancies.…”

“…Importantly, this study validates previous study finding of asymmetric sinus disease on CT imaging, as an early predictor of AIFS. 13 The proposed scoring system could be utilized to risk stratify select patients consulted for AIFS evaluation, to reduce invasive procedures and length of serial examination, although hastening involvement of subspecialty 15 ; however, scoring must be validated in a prospective manner. The "AIFS Unlikely" and "AIFS Highly Likely" categories have a high negative predictive value and positive predictive value respectively, lending credence to the system's clinical utility to rule patients in or out for a AIFS diagnosis.…”