AAAAI - Fungi Stake a Claim in Allergic Sinusitis Pathology

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March 25, 2008

AAAAI - Fungi Stake a Claim in Allergic Sinusitis Pathology

by Neil Osterweil, Senior Associate Editor, MedPage Today

Published: February 28, 2007

Reviewed by _ Jasmer, MD_

(http://www.medpagetoday.com/reviewer.cfm?reviewerid=55) ; Associate Clinical

Professor of Medicine, University of

California, San Francisco

SAN DIEGO, Feb. 28 -- Allergic fungal sinusitis deserves a place of its own

at the table of nasty chronic rhinosinusitis infections, researchers

asserted here.

It may account for up to 10% of chronic rhinosinusitis, said S.

Hutcheson, of Saint Louis University Medical School, at a briefing during the

American Academy of Allergy, Asthma, & Immunology meeting here.

Action Points

· Explain to patients who ask that some researchers suspect fungi as

the source of a large proportion of chronic sinus infections. This study

suggests that allergic fungal sinusitis may be an entity distinct from chronic

rhinosinusitis.

· This study was published as an abstract and presented as a poster

and orally in a briefing at a conference. These data and conclusions should

be considered to be preliminary as they have not yet been reviewed and

published in a peer-reviewed publication.

" Allergic fungal sinusitis appears to be a separate and distinct form of

chronic rhinosinusitis, " she said.

Clinically, patients with allergic fungal sinusitis look pretty much the

same as those with chronic rhinosinusitis of non-fungal origin, but the

serology

tells a different story, said G. Slavin, M.D., director of the

division of allergy & immunology, at Saint Louis University, who headed the

research team.

The question is, however, what can be done about it?

" With allergic fungal sinusitis, certainly the most successful treatment has

been long term prednisone, " Dr. Slavin said. " There is great controversy

about antifungal treatment of chronic rhinosinusitis, and as a matter of fact

there is now an ongoing multicenter double-blind placebo study on intranasal

amphotericin B, and there's also one in the offing on oral itraconazole

[sporanox] for chronic rhinosinusitis, following the Mayo Clinic proposition

that

the vast majority are due to fungi. "

In a study of 84 patients with chronic rhinosinusitis and nasal polyps who

underwent nasosinus surgery, the authors found that the patients with fungal

infection had total immunglobulin E (IgE), specific immunoglobulin G (IgG)

anti-Alternaria mold antibody, and specific IgE against seven different fungi

were significantly elevated compared with patients with chronic

rhinosinusitis. Also IgE appears to play an important role in the pathogenesis

of the

fungal infections.

The investigators came to their conclusions after recovering exudates from

the patients, culturing them and examining them by histology for the presence

of eosinophils, Charcot-Leyden crystals (breakdown products of eosinophils),

and for fungal elements, such as hyphae.

They also looked for serum total IgE and IgG anti-Alternaria antibodies, and

looked for evidence of six additional fungal species including Aspergillus,

Bipolaris, Curvularia, Epicoccum, Fusarium and Phoma.

They found that the exudates from 66 patients had high numbers of

eosinophils, visible fungal hyphae, or were culture positive, and these

patients were

designated as having allergic fungal sinustitis. An additional 18 patients

were labeled as having standard (non-fungal) chronic rhinosinusitis.

Both the serum total IgE and specific IgG anti-Alternaria were statistically

significantly elevated in the allergic fungal compared to the chronic

rhinosinusitis group. The total mean IgE was 1,080 IU/ml (range, 28-12,230

IU/ml)

for patients with fungal infections, compared with 324 IU/ml (range 8.8-1081

IU/ml) for those without evidence of fungal infection.

The mean specific IgG-anti-Alternaria 40.6 mg/l (range 0-182 mg/l) for

those with allergic fungal sinusitis, and 8.2 mg/l (range 2-37.7 mg/l) for

those

with chronic sinusitis.

Among the 15 patients who were tested for the presence of all seven fungi,

immunoblotting tests for IgE anti-fungi showed multiple bands to all fungi in

nine of 10 patients with allergic fungal infections, compared with none of

five patients with chronic rhinosinusitis. The number of positive bands for

each fungus was significantly higher among patients with allergic fungal

sinusitis compared with those with chronic rhinosinusitis.

" A significant and distinct immune response was observed in allergic fungal

sinusitis subjects that was different from that seen in chronic

rhinosinusitis subjects, " Hutcheson said. " The antibody responses reflect our

view that

IgE antibodies do indeed play an important role in the differences seen in

allergic fungal sinusitis subjects, and this distinguishes them from chronic

rhinosinusitis subjects. "

" IgG is also increased in these subjects, probably due to a heightened

general inflammatory resposnse, " she continued. " Interestingly, the one chronic

rhinosinusitis patient in whom IgE reactivity was seen against all seven fungi

had twice the specific IgG-anti-Alternatira level of any other chronic

rhinosinusitis subject. "

http://www.medpagetoday.com/MeetingCoverage/AAAAIMeeting/tb/5135

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