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An Approach to Fulminant Invasive Fungal Rhinosinusitis in the Immunocompromised Host
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Cancer Biol Ther ; 2 : — Toll-like receptors and human disease: lessons from single nucleotide polymorphisms. Curr Genomics ; 13 : — Adaptive immunity to fungi. Annu Rev Immunol ; 30 : — D , Axial CT shows a surgically proved subtle ulceration along the left side of the nasal septum arrowhead in a fourth patient. Illustration of less commonly described areas of AIFR, including the nasolacrimal duct, lacrimal sac, and nasopharynx.
A , Contrast-enhanced axial CT image shows soft-tissue thickening and inflammatory stranding in the area of the left lacrimal sac white arrow and in the medial orbit white arrowhead. The normal right nasolacrimal duct curved arrow is identified for comparison. Asymmetric unilateral mucosal disease is also seen in the left ethmoid air cells asterisk.
B , Coronal image again shows thickening and inflammatory change in the left lacrimal sac white arrow and medial orbit black arrowhead. Similar inflammatory changes are seen in the left nasolacrimal duct white arrowhead.
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C , Axial CT in a different patient with AIFR with marked asymmetric mucosal thickening of the right nasal cavity asterisk and right nasopharynx arrow. D , Axial contrast-enhanced CT in a third patient with marked asymmetric mucosal thickening in the left nasopharynx arrow and subtle inflammatory stranding involving the left parapharyngeal fat arrowheads.
Examples of advanced manifestations of AIFR. A and B , Axial postcontrast CT images show a filling defect in the right cavernous sinus white arrowhead with adjacent parenchymal hyperattenuation or focal area of enhancement curved arrow most consistent with an acute hemorrhagic infarction in the right anterior temporal pole or parenchymal involvement by AIFR, respectively. There is also partial thrombosis of the right internal carotid artery white arrow. C , Postcontrast coronal CT in a different patient shows subtle left epidural thickening along the floor of the middle cranial fossa white arrow.
D , Axial noncontrast CT in a third patient shows soft-tissue infiltration of the right sphenopalatine foramen and pterygopalatine fossa black arrowhead , with extension into the right orbital apex white arrowhead.
Correlation of the degree of opacity in the nasal cavity and paranasal regions with specificity A and sensitivity B. Increasing opacity, particularly in the nasal cavity, nasopharynx, and posterior ethmoid air cells, has a strong correlation with specificity for AIFR. A decrease in sensitivity is also evident as the degree of opacity increases. Laterality data were initially collected to determine whether a unilateral predominance existed. Unilateral AIFR was present in Only the right side was affected in We did not find that laterality added additional predictive value to our models; therefore, laterality data were consolidated for further analysis using the highest unilateral score.
We balanced statistical rigor of multivariate stepwise regression minimizing Akaike Information Criterion with the clinical reality of maximizing positive predictive value PPV and negative predictive value NPV to generate a 7-variable diagnostic model to predict AIFR On-line Table.go site
What symptoms does acute invasive fungal sinusitis display?
The top 4 variables in the model periantral fat, pterygopalatine fossa, nasolacrimal duct, and lacrimal sac were the most correlated with AIFR. These variables highly intercorrelated themselves and were present in most or all of the numerous statistical models generated during this evaluation. Illustration of the number of co-occurring positive variables 7-variable model in patients with AIFR versus controls. We present a simple-yet-accurate CT-based clinical model derived from a large single-institution study that can exclude or diagnose AIFR with a higher degree of confidence than suggested previously.
This model has variables that have been previously ascribed to characteristic imaging findings for AIFR 1 , 8 , 10 , 11 periantral fat, bone dehiscence, orbital invasion, pterygopalatine fossa , as well as uncommonly described markers for AIFR such as nasolacrimal duct and lacrimal sac involvement. The power of the clinical model resides in the aggregate evaluation of all 7 variables because no individual variable had both high PPV and high NPV.
Therefore, bone destruction alone is not a useful exclusionary criterion.
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This phenomenon likely explains the high correlation seen with involvement of the sphenopalatine foramen and ipsilateral pterygopalatine fossa, suggesting extension from the nasal cavity along either posterior superior nasal nerves or the sphenopalatine artery. This is in contradistinction to isolated involvement of the posterior periantral fat, which is more likely related to direct extension from the maxillary sinus along vascular channels. Our study agrees with previous literature implicating severe nasal cavity mucosal thickening on CT as a common finding in patients with AIFR.
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Consequently, unilateral nasal cavity disease may not be a reliable individual predictor of AIFR. The correlation of AIFR with the severity of mucosal thickening was also present in areas outside the nasal cavity. We found a significant relationship between the incidence of AIFR and the degree of mucosal disease in 6 of 8 measured regions; however, incorporating such dependency on variable progression of mucosal disease proved difficult and unnecessary.
We opted for a clinical model that offered high PPV and high NPV, independent of opacity assignments for simpler clinical applicability. However, we were unable to identify any specific indictors of prognosis from our data—that is, in no region was disease involvement indicative of patient mortality. This was somewhat surprising because findings classically considered early-stage and late-stage factors were both present in our patients. If these monikers are accurate, patients presenting with so-called late-stage symptoms would be expected to have relatively high mortality, but this was not the case.
For example, none of the 7 patients who died of AIFR presented with bone dehiscence. This outcome suggests caution in predicting a time course of disease or prognosis based on findings previously considered late-stage findings. This finding led to the recommendation that CT be considered a second-line technique. Moreover, our predictive model even produces higher sensitivity, specificity, and NPV than previously reported with CT. Thus, on the basis of our results, CT with application of our predictive model should be considered a primary technique for evaluating AIFR.
Several limitations in our study are noteworthy. First, the rarity of AIFR necessitated a retrospective study design to capture a large number of cases. Readers were blinded to all clinical data to minimize bias, but that is a concern in retrospective designs.
What is Invasive Fungal Sinusitis?
Second, some selection bias is inherent because the control group all progressed to endoscopy or surgery, suggesting higher clinical suspicion of sinus disease. Third, we purposely selected a patient control group with predisposing conditions to AIFR so that our clinical model would be applicable to the interpreting radiologist evaluating possible AIFR among an at-risk patient population in a real-world clinical environment.
Consequently, some caution is warranted in extrapolating our results to other patient groups in which AIFR is not the clinical concern. We propose a CT-based model to help exclude or diagnose AIFR with a higher degree of confidence than suggested previously. Indicates open access to non-subscribers at www. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.
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