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Unusual fungal pathogens in fungal rhinosinusitis
FUNGAL RHlNOSINUSITIS: A SPECTRUM OF DISEASE
0030-6665/00 $15.00 + .00
UNUSUAL FUNGAL PATHOGENS IN FUNGAL RHINOSINUSITIS Wiley A. Schell, MS
The number of fungal species is estimated to be as many as 1.5 million. Roughly 70,000 of these species have been discovered, and about 500 to 800 more are described each year.23 Of these, approximately 300 have been documented as causing disease in humans and other animals." Certain of these species clearly are more virulent than others and are responsible for disproportionate numbers of infections. Some of the remaining species cause enough morbidity or mortality to be considered emerging pathogens." A full recognition of the medical challenge posed by fungi requires acceptance of the concept that quite a few more than these 300 species probably have the potential to cause disease in humans under favorable circumstances. This presents several problems in medical mycology, two of which are documentation of unusual fungal pathogens and fostering a wider awareness of them. THE PROBLEM OF REPORTING It is the consensus of those engaged in medical mycology that the incidence of mycoses and the recognized diversity of etiologic agents are increasing. Unfortunately, the true incidence and associated human and monetary costs of these infections remain unknown. Currently there is no federal mandate for the reporting of fungal diseases nor has funding been available for voluntary efforts." As a result, one relies mainly on reports in the medical literature to infer conclusions about the relative incidence
From the Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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of various pathogenic fungi. Obviously this sometimes leads to incorrect beliefs. For example, species of Aspergillus are frequent causes of sinusitis, and for many years it was assumed that septate hyphae seen during microscopic examination of clinical specimens denoted aspergillosis. Gradually, however, it became clear instead that species of the dematiaceous genera, such as Alternaria, Curoularia, and Bipolaris, when taken as a group are the predominant causes in certain syndromes of rhinosinusitis, and that the hyphae of these species seen in tissue can closely resemble those of Aspergillus species. Such advances in knowledge can be slow to develop and become widely recognized. One explanation for this is that the frequency of case reports of unusual agents often tends to be bimodal. Following the first report of a newly recognized etiologic agent, a second and perhaps third report might follow. Thereafter the use of reporting additional cases is less compelling, both for would-be authors and journal editors, and these experiences frequently go unreported. A second round of publications may follow if individuals encounter several additional cases that permit them to report a small series and perhaps incorporate a review of previous reports. To illustrate, immediately following publication of Nodulisporium species as a cause of sinusitis, a second case was encountered (personal communication, South Carolina Department of Health, 1994) but never has been published. Other examples include at least three cases of sinusitis caused by Schizophyllum commune, and at least two of Scedosporium apiospermum seen at the author's institution that never have been reported. Of the fungi listed in Table 1, some are quite rare as agents of rhinosinusitis and probably will remain so. Others simply are unusual in the main sense. A few, such as Paecilomyces lilacinus, S commune, and certain species of Fusarium, may prove to be numerous enough that they will be excluded in the future. DOCUMENTATION OF FUNGAL ETIOLOGY
Complete documentation of fungal etiology in a given case includes several factors. First, there should be sound evidence that a disease exists. Positive culture results alone usually are not sufficient evidence. As mentioned previously, almost all of these fungi produce airborne spores and most are Widespread in the environment. As a result, many of these species occasionally appear on culture media in the absence of disease. Second, the fungus should be seen in the clinical specimen, and toward this end it is particularly important that a sensitive method of microscopy be used. The morphology of the fungus seen in the clinical speciments) must be compatible with the fungus recovered in culture. Microscopy and culture results initially may be contradictory in some cases, but careful review of both usually permits resolution. The recovered fungus must be identified properly. Fungal identification, even to the genus level, often can be difficult and errors are more likely if an unusual fungus is encountered. Identification to the species
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Table 1. UNUSUAL FUNGAL PATHOGENS IN RHINOSINUSITIS' Fungal Group
Fungust
Syndromes
References
Ascomycetes
Chaetomium globosum
FB?
2
Basidiomycetes
Schizophyllllm commllne
NS AFS
47 13 25 46
CN1
AFS CI
42
AI
38:1:
DicymaampulliJcrn (Ascotricha chartarum) Dissitimurus exedms Exserohilum mcgi/misii Nodulisporium hillllU/eum Phaeoocremoniunl species Scedosporillm apiospermum (Pseudallescherin boydiJ1 Scedosporillln prolificans Scytalidillm dilllidiatllm Scopulariopsis sp. (Microosclls cinerells) Sporothrix schellckii
CI NS CI AFS NS FB,CI
50 49 36 14 30,48 21,52.54
AI,FB NS C AI?
11,55 31 3 1,33
Aspergillus avenacells Aspergillus quadrilineatus (Emericella qlladrilineatn) Aspergillus nidulellus tBmericella nidllians) Aspergi1lus oryme Pusarium species Pusarium proliferatum Fusarium solani Histoplasma capsllintum Microsporlllll ennis Myriodolltillm keratinophi/ulll Paecilomyces species Paecilomyces variotii Paecilomyces IiIncinus Penicillium species Scopumriopsis acremoniulll Scapular/apsis candida
CI AI
37
NS AI,CN! FB AI AI
15,32 10 5,40 4 27 9 6 29 43 51 20,39,44 35 18 26
Yeasts
Candida albicans CryptocoCCIIS neojormans
AI? AI?
19 12
Zygomycetes
Absidill corymbifern Basidiobolus rnnarum Conidiobollls coronatlls§ Conidiobo/lls incongruus Crmninghamelln bertholetine Mucor ramosissimus R1Iizopus microsporus var. rhizopoditormis Saksenaea vasiJormis
AI (RCZJ AI (RCZ)
28 17
Hyphomycetes, dematlaceous
Hyphomycetes, hyaline
FB?, FB AI AI,AI? AI AI AI? NS AFS
AI (RCZJ AI (RCZJ AI (RCZ) AI (RCZ) AI (RCZ)
53
7 34
8 41 24
AFS = allergic fungal sinusitis; AI (RCZ) = acute invasive, rhinocerebral zygomycosis; CI = chronic invasive; CNI - chronic noninvasive; FB = fungus ball; NS - not specified. "Someunique cases were excluded if the identity of the fungus was neither clearly Illustrated nor attributed to a mycology authority. Inclusion of other fungi in this table was based largely on how often species of a given genus are routinely identified. In some instances, specifically identified species have been grouped under their genus name (e.g., Bipo/nris linwaliL'IIsis as Bipolnris species) and arbitrarily excluded from the table as being among the more frequent causes offungal rhinosinusltis. This was not followed for Fusarium species because these species are more unusual causes of rhinosinusitis. tFungi having both sexual and asexual morphs are listed under the asexual name because this morph is the first to arise in culture. U the sexual form is likely to be seen as well, its name is included in parentheses. tSinusitls is inferred from the presence of palate lesions. §Rare in North America; endemic in certain other regions.
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level usually is demanding, and confirmation by a reference laboratory is encouraged. Molecular approaches to the taxonomy of some of these agents has led to proposals for extensive revisions, which present greater challenges to laboratorians, and potential confusion for clinicians. Any culture reports listing the name of a fungal pathogen that may be unfamiliar to physicians should include interpretations, and the laboratory director should contact physicians to discuss potentially significant findings. In some cases, not all criteria for complete documentation of an unusual etiology can be satisfied. The most problematic circumstance is a positive culture finding in conjunction with negative specimen microscopy. It is essential to evaluate mycology culture results carefully and without prejudice. This is because nearly all of the fungi listed (see Table 1) can be encountered as nonsignificant isolates or as outright contaminants, but conversely, these and other moulds can cause rhinosinus disease and must not be dismissed quickly as unimportant findings. Isolation of a mould from an otolarygologic specimen is always suspicious, and any fungus that previously has been documented as a cause of otolaryngologic disease is particularly so. Although as little as a single colony can be significant, evaluation of cultures should include enumeration of colonies, and notation of whether growth is present in more than one culture vessel. Culture media also should be closely examined to determine whether growth has arisen directly from inocula or instead appears to have arisen apart from the inoculation streaks. These observations can be helpful in determining if a mould might be a culture contaminant. PRACTICAL APPLICATIONS
As yet, there are few standard therapies for the treatment of fungal rhinosinusitis. Differences in pathogenicity as well as susceptibility to antifungal drugs, however, are starting to become apparent for various fungal species. Accurate identification is warranted of genus at least, and species when possible, and can play an important role in determining the choice of treatment for a given case. Treatment options for fungal infections as a whole have increased significantly in the last 10 years, and entirely new classes of drugs with novel mechanisms of action currently are in development. Accurate identification of cause is likely to become increasingly important for the assessment of treatment outcomes as these newer antifungal compounds become available to clinicians. Toward these ends, unusual fungi can be deposited free of charge to the American Type Culture Collection (Manassas, VA) for preservation and subsequent distribution to researchers. References 1. Agger WA, Caplan RB, Maki DG: Ocular sporotrichosis mimicking mucormycosis in a diabetic. Ann Ophthalmol10:767, 1978
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2. Am A, Munk-Nielsen L, Federspiel BH: The soil fungus Chaetomium in the human paranasal sinuses. Eur Arch Otorhinolaryngol 254:350, 1997 3. Aznar C, de Bievre C, Guiguen C: Maxillary sinusitis from Microascus cinereus and Aspergillus repens. Mycopathologia 105:93, 1989 4. Barrios N], Kirkpatrick DV, Murciano A, et al: Successful treatment of disseminated fusarium infection in an immunocompromised child. Am J Ped Hematol-DncoI12:319, 1990 5. Blazar BR, Hurd DD, Snover DC, et al: Invasive fusarium infections in bone marrow transplant recipients. Am] Med 77:645, 1984 6. Braun H, Gentine A, Koenig H, et al: Une sinusite maxillaire caseeuse d' origine dentaire exceptionnelle a Microsporum canis. Ann Otolaryngol Chir Cervicofac 110:346, 1993 7. Brennan RO, Crain BJ, Proctor AM, et al: Cunninghamella: A newly recognized cause of rhinocerebral murcormycosis, Am J Clin PathoI80:98, 1983 8. Bullock JO, ]ampol LM, Fezza A]: Two cases of orbital phycomycosis with recovery. Am J OphthaImol 78:811,1974 9. Butt AA, Carreon]: Histoplasma capsulaium sinusitis. J Clin MicrobioI35:2649, 1997 10. Byard RN, Bonin RA, Haq AU: Invasion of paranasal sinuses by Aspergillus onJZlIe. Mycopathologia 96:41, 1986 11. Chikhani L, Dupont B, Guilbert P, et al: Une sinusite maxillaire fongique exceptionnelle d'origine dentaire a Scedosporium prolificans. Rev Stomatol Chir Maxillofac 96:66, 1995 12. Choi 55, Lawson W, Bottone E], et al: Cryptococcal sinusitis: A case report and review of literature. Otolaryngol Head Neck 5urg 99:414, 1988 13. Clark 5, Campbell CK, Sandison A, et al: SchizophylluJn commune: An unusual isolate from a patient with allergic fungal sinusitis. J Infect 32:147,1996 14. Cox GM, Schell WA, Scher RL, et al: First report of involvement of Nodulisporium species in human disease.] Clin MicrobioI32:2301, 1994 15. Doby}M, Kombila-Favry M: Presence de formes sexuees (cleistotheces et Hulle cells) dans un cas humain d'aspergillose du sinus maxillaire chez Aspergillus nlduians associe 11 Aspergillus [umigatus. Mycopathologia 64:157,1978 16. Drouhet E: Historical introduction: Evolution of knowledge of the fungi and mycoses from Hippocrates to the twenty-first century. In Ajello L, Hay R] (eds): Medical Mycology, Topley & Wilson's Microbiology and Microbial Infections, ed 9. London, Edward Arnold, Ltd, 1998, P 4 17. Dworzack DL, Pollock AS, Hodges GR, et al: Zygomycosis of the maxillary sinus and palate caused by Basidiobolus haptosporus. Arch Intern Med 138:1274, 1978 18. Ellison MD, Hung RT, Harris K, et al: Report of the first case of invasive fungal sinusitis caused by Scopulariopsis acremonium: Review of Scopulariopsis infections. Arch Otolaryngol Head Neck 5urg 124:1014,1998 19. Grigoriu D, Bambule J, Delacretaz ], et a1: La sinusite maxillaire fongique. Dermatologica 159:180, 1979 20. Gucalp R, Carlisle P, Gialanella P,et al: Paecilomyces sinusitis in an immunocomprornised adult patient: Case report and review. Clin Infect Dis 23:391,1996 21. Guez S, Calas V, Couprie B, et al: A propos de deux cas d'infection nasosinusienne a Scedosporium apiospermum. Rev Med Interne 13:145, 1992 22. Halde C, Valesco M, Flores M: The need for a mycoses reporting system. In Borgers M, Hay R, Rinaldi MG (eds): Current Topics in Medical Mycology, vol 4. New York, Springer-Verlag, 1992, p 259 23. Hawksworth DL, Kirk PM, Sutton BC, et al: Ainsworth & Bisby's Dictionary of the Fungi, ed. 8. Wallingford, Oxon, England, Commonwealth AgricuItureal Bureaux, 1995, p 315 24. Kaufman L, Padhye AA, Parker 5: Rhinocerebral zygomycosis caused by Snksenaea vasi/ormis. Journal of Medical and Veterinary Mycology 26:237, 1988 25. Kern ME, Uecker FA: Maxillary sinus infection caused by the homo basidiomycetous fungus Schizophyllum commune.] Clin MicrobioI23:1001, 1986 26. Kriesel ]D, Adderson EE, Gooch WM III, et al: Invasive sinonasal disease due to Scopulariopsis candida: case report and review of Scopulariopsis. CIin Infect Dis 19:317, 1994 27. Kurien M, Annadi V, Raman R, et al: Maxillary sinus fusariosis in immunocompetent hosts.] Laryngol Otol106:733, 1992
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28. Manso E, Montillo M, Frongia G, et al: Rhinocerebral mucormycosis caused by Absidia corymbifera: An unusual localization in a neutropenic patient. Journal of Medical and Veterinary Mycology 4:104,1994 29. Maran AGD, Kwong K, Milne LJR, et al: Frontal sinusitis caused by Myriodontium keratinophilum. BMJ 290:207,1985 30. Marriott DJE, Wong KH, Azner E, et al: Scytalidium dimidiatum and Lecythophora hoftnannii: Unusual causes of fungal infections in patients with AIDS. J Clin MicrobioI35:2949, 1997 31. Miegeville M, Krempf M, Legent F, et al: Scytalidium forme arthrosporee de Hendersonula ioruloidea isole d'une necrose du maxillaire chez un diabetique francais. Bulletin de la Societe Francaise de Mucologie Medicale 15:427, 1986 32. Mitchell RG, Chaplin AJ, Mackenzie DWR: Emericella nidulans in a maxillary sinus fungal mass. J Med Vet Mycol 25:339, 1987 33. Morgan MA, Wllson WR, Neel BH ill, et al: Fungal sinusitis in healthy and immunocompromised individuals. Am J Clin PathoI82:597, 1984 34. Ng TIC, Campbell CK, Rothera M, et al: Successful treatment of sinusitis caused by Cunninghamella bertholetiae. Clin Infect Dis 19:313, 1994 35. Nouri ME: Penicillinose der Nasennebenhohlen. Laryngologie Rhinologie Otologie (Stuttg) 65:420, 1986 36. Padhye AA, Ajello L, Wieden MA, et al: Phaeohyphomycosis of the nasal sinuses caused by a new species of Exserohiium. J Clin MicrobioI24:245, 1986 37. Polacheck I, Nagler A, Okon E, et al: Aspergillus quadriltneatus, a new cause of fungal sinusitis. JClin Microbiol 30:3290, 1992 38. Restrepo A, Greer DL, Robledo M, et al: Ulceration of the palate caused by a Basidiomycete, Schizophyllum commune. Sabouraudia 11:201, 1973 39. Rockhill RC, Klein MD: Paecilomyces lilacinus as the cause of chronic maxillary sinusitis. J Clin Microbial 11:737, 1980 40. Rombaux P, Eloy P, Bertrand B, et al: Lethal disseminated Fusarium infection with sinus involvement in the immunocompromised host: Case report and review of the literature. Rhinology 34:237,1996 41. Rosenberger RS, West BC, King JW: Survival from sino-orbital mucormycosis due to Rhizopus rhizopodiJormis. Am J Med Sci 286:25,1983 42. Rosenthal J, Katz R, DuBois DB, et al: Chronic maxillary sinusitis associated with the mushroom Schizophyllum commune in a patient with AIDS. Clin Infect Dis 14:46, 1992 43. Rowley SO, Strom CG: Paecilomyces fungus infection of the maxillary sinus. Laryngoscope 92:332, 1982 44. Saberhagen C, Klotz SA, Bartholomew W, et al: Infection due to Paecilomyces lilacinus: A challenging clinical identification. Clin Infect Dis 25:1411,1997 45. Schell WA: New aspects of emerging fungal pathogens. In Christie JD (ed): Clinics in Laboratory Medicine. Philadelphia, WB Saunders, 1995, p 368 46. Sigler L, Bartley JR, Parr DH, et al: Maxillary sinusitis caused by medusoid form of Schizophyllum commune. J Din MicrobioI37:3395, 1999 47. Sigler L, Estrada 5, Montealegre NA, et al: Maxillary sinusitis caused by Schizophyllum commune and experience with treatment. Journal of Medical and Veterinary Mycology 35:365, 1997 48. Sigler L, Kennedy MJ: Aspergillus, Fusarium, and other opportunistic moniliaceous fungi. In Murray PR, Baron EJ, Pfaller MA, et al (eds): Manual of Clinical Mycology, ed 7. Washington, DC, American Society for Microbiology, 1999,P 1235 49. Simmons EG, McGinnis MR, Rinaldi MG: Dissiiimurus, a new dematiaceous genus of Hyphomycetes. Mycotaxon 30:247, 1987 50. Singh SM, Naidu J, Jain S, et al: Maxillary sinusitis caused by Ascotricha chartarum Berk (anamorph Dicyma ampll/lifera Boul): A new phaeoid opportunistic human pathogen. Journal of Medical and Veterinary Mycology 34:215,1996 51. Thompson RF, Bode RB, Rhodes JC, et al: Paecilomyces variotii. An unusual cause of isolated sphenoid sinusitis. Arch Otolaryngol Head Neck Surg 114:567,1988 52. Travis LB, Roberts GO, Wilson WR: Clinical significance of Pseudallescheria boydii: A review of 10 years' experience. Mayo Clin Proc 60:531, 1985 53. Washburn RG, Kennedy DW, Begley MG, et al: Chronic fungal sinusitis in apparently normal hosts. Medicine 67:231, 1988
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54. Watters GW, Milford CA: Isolated sphenoid sinusitis due to Pseudaltescheria boydU. ] Laryngol Otol107:344, 1993 55. Wood GM, McCormack ]G, Muir DB, et al: Clinical features of human infection with Scedosporium inflaturn. Clin Infect Dis 14:1027, 1992
Address reprint requests to Wiley A. Schell, MS Box 3303 Division of Infectious Diseases Department of Medicine Duke University Medical Center Durham, NC 27710
0030-6665/00 $15.00 + .00
UNUSUAL FUNGAL PATHOGENS IN FUNGAL RHINOSINUSITIS Wiley A. Schell, MS
The number of fungal species is estimated to be as many as 1.5 million. Roughly 70,000 of these species have been discovered, and about 500 to 800 more are described each year.23 Of these, approximately 300 have been documented as causing disease in humans and other animals." Certain of these species clearly are more virulent than others and are responsible for disproportionate numbers of infections. Some of the remaining species cause enough morbidity or mortality to be considered emerging pathogens." A full recognition of the medical challenge posed by fungi requires acceptance of the concept that quite a few more than these 300 species probably have the potential to cause disease in humans under favorable circumstances. This presents several problems in medical mycology, two of which are documentation of unusual fungal pathogens and fostering a wider awareness of them. THE PROBLEM OF REPORTING It is the consensus of those engaged in medical mycology that the incidence of mycoses and the recognized diversity of etiologic agents are increasing. Unfortunately, the true incidence and associated human and monetary costs of these infections remain unknown. Currently there is no federal mandate for the reporting of fungal diseases nor has funding been available for voluntary efforts." As a result, one relies mainly on reports in the medical literature to infer conclusions about the relative incidence
From the Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina
OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA VOLUME 33' NUMBER 2' APRIL 2000
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SCHELL
of various pathogenic fungi. Obviously this sometimes leads to incorrect beliefs. For example, species of Aspergillus are frequent causes of sinusitis, and for many years it was assumed that septate hyphae seen during microscopic examination of clinical specimens denoted aspergillosis. Gradually, however, it became clear instead that species of the dematiaceous genera, such as Alternaria, Curoularia, and Bipolaris, when taken as a group are the predominant causes in certain syndromes of rhinosinusitis, and that the hyphae of these species seen in tissue can closely resemble those of Aspergillus species. Such advances in knowledge can be slow to develop and become widely recognized. One explanation for this is that the frequency of case reports of unusual agents often tends to be bimodal. Following the first report of a newly recognized etiologic agent, a second and perhaps third report might follow. Thereafter the use of reporting additional cases is less compelling, both for would-be authors and journal editors, and these experiences frequently go unreported. A second round of publications may follow if individuals encounter several additional cases that permit them to report a small series and perhaps incorporate a review of previous reports. To illustrate, immediately following publication of Nodulisporium species as a cause of sinusitis, a second case was encountered (personal communication, South Carolina Department of Health, 1994) but never has been published. Other examples include at least three cases of sinusitis caused by Schizophyllum commune, and at least two of Scedosporium apiospermum seen at the author's institution that never have been reported. Of the fungi listed in Table 1, some are quite rare as agents of rhinosinusitis and probably will remain so. Others simply are unusual in the main sense. A few, such as Paecilomyces lilacinus, S commune, and certain species of Fusarium, may prove to be numerous enough that they will be excluded in the future. DOCUMENTATION OF FUNGAL ETIOLOGY
Complete documentation of fungal etiology in a given case includes several factors. First, there should be sound evidence that a disease exists. Positive culture results alone usually are not sufficient evidence. As mentioned previously, almost all of these fungi produce airborne spores and most are Widespread in the environment. As a result, many of these species occasionally appear on culture media in the absence of disease. Second, the fungus should be seen in the clinical specimen, and toward this end it is particularly important that a sensitive method of microscopy be used. The morphology of the fungus seen in the clinical speciments) must be compatible with the fungus recovered in culture. Microscopy and culture results initially may be contradictory in some cases, but careful review of both usually permits resolution. The recovered fungus must be identified properly. Fungal identification, even to the genus level, often can be difficult and errors are more likely if an unusual fungus is encountered. Identification to the species
UNUSUALFUNGAL PATHOGENS IN FUNGALRHINOSINUSmS
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Table 1. UNUSUAL FUNGAL PATHOGENS IN RHINOSINUSITIS' Fungal Group
Fungust
Syndromes
References
Ascomycetes
Chaetomium globosum
FB?
2
Basidiomycetes
Schizophyllllm commllne
NS AFS
47 13 25 46
CN1
AFS CI
42
AI
38:1:
DicymaampulliJcrn (Ascotricha chartarum) Dissitimurus exedms Exserohilum mcgi/misii Nodulisporium hillllU/eum Phaeoocremoniunl species Scedosporillm apiospermum (Pseudallescherin boydiJ1 Scedosporillln prolificans Scytalidillm dilllidiatllm Scopulariopsis sp. (Microosclls cinerells) Sporothrix schellckii
CI NS CI AFS NS FB,CI
50 49 36 14 30,48 21,52.54
AI,FB NS C AI?
11,55 31 3 1,33
Aspergillus avenacells Aspergillus quadrilineatus (Emericella qlladrilineatn) Aspergillus nidulellus tBmericella nidllians) Aspergi1lus oryme Pusarium species Pusarium proliferatum Fusarium solani Histoplasma capsllintum Microsporlllll ennis Myriodolltillm keratinophi/ulll Paecilomyces species Paecilomyces variotii Paecilomyces IiIncinus Penicillium species Scopumriopsis acremoniulll Scapular/apsis candida
CI AI
37
NS AI,CN! FB AI AI
15,32 10 5,40 4 27 9 6 29 43 51 20,39,44 35 18 26
Yeasts
Candida albicans CryptocoCCIIS neojormans
AI? AI?
19 12
Zygomycetes
Absidill corymbifern Basidiobolus rnnarum Conidiobollls coronatlls§ Conidiobo/lls incongruus Crmninghamelln bertholetine Mucor ramosissimus R1Iizopus microsporus var. rhizopoditormis Saksenaea vasiJormis
AI (RCZJ AI (RCZ)
28 17
Hyphomycetes, dematlaceous
Hyphomycetes, hyaline
FB?, FB AI AI,AI? AI AI AI? NS AFS
AI (RCZJ AI (RCZJ AI (RCZ) AI (RCZ) AI (RCZ)
53
7 34
8 41 24
AFS = allergic fungal sinusitis; AI (RCZ) = acute invasive, rhinocerebral zygomycosis; CI = chronic invasive; CNI - chronic noninvasive; FB = fungus ball; NS - not specified. "Someunique cases were excluded if the identity of the fungus was neither clearly Illustrated nor attributed to a mycology authority. Inclusion of other fungi in this table was based largely on how often species of a given genus are routinely identified. In some instances, specifically identified species have been grouped under their genus name (e.g., Bipo/nris linwaliL'IIsis as Bipolnris species) and arbitrarily excluded from the table as being among the more frequent causes offungal rhinosinusltis. This was not followed for Fusarium species because these species are more unusual causes of rhinosinusitis. tFungi having both sexual and asexual morphs are listed under the asexual name because this morph is the first to arise in culture. U the sexual form is likely to be seen as well, its name is included in parentheses. tSinusitls is inferred from the presence of palate lesions. §Rare in North America; endemic in certain other regions.
370
SCHELL
level usually is demanding, and confirmation by a reference laboratory is encouraged. Molecular approaches to the taxonomy of some of these agents has led to proposals for extensive revisions, which present greater challenges to laboratorians, and potential confusion for clinicians. Any culture reports listing the name of a fungal pathogen that may be unfamiliar to physicians should include interpretations, and the laboratory director should contact physicians to discuss potentially significant findings. In some cases, not all criteria for complete documentation of an unusual etiology can be satisfied. The most problematic circumstance is a positive culture finding in conjunction with negative specimen microscopy. It is essential to evaluate mycology culture results carefully and without prejudice. This is because nearly all of the fungi listed (see Table 1) can be encountered as nonsignificant isolates or as outright contaminants, but conversely, these and other moulds can cause rhinosinus disease and must not be dismissed quickly as unimportant findings. Isolation of a mould from an otolarygologic specimen is always suspicious, and any fungus that previously has been documented as a cause of otolaryngologic disease is particularly so. Although as little as a single colony can be significant, evaluation of cultures should include enumeration of colonies, and notation of whether growth is present in more than one culture vessel. Culture media also should be closely examined to determine whether growth has arisen directly from inocula or instead appears to have arisen apart from the inoculation streaks. These observations can be helpful in determining if a mould might be a culture contaminant. PRACTICAL APPLICATIONS
As yet, there are few standard therapies for the treatment of fungal rhinosinusitis. Differences in pathogenicity as well as susceptibility to antifungal drugs, however, are starting to become apparent for various fungal species. Accurate identification is warranted of genus at least, and species when possible, and can play an important role in determining the choice of treatment for a given case. Treatment options for fungal infections as a whole have increased significantly in the last 10 years, and entirely new classes of drugs with novel mechanisms of action currently are in development. Accurate identification of cause is likely to become increasingly important for the assessment of treatment outcomes as these newer antifungal compounds become available to clinicians. Toward these ends, unusual fungi can be deposited free of charge to the American Type Culture Collection (Manassas, VA) for preservation and subsequent distribution to researchers. References 1. Agger WA, Caplan RB, Maki DG: Ocular sporotrichosis mimicking mucormycosis in a diabetic. Ann Ophthalmol10:767, 1978
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