Recycling plastic: diagnosis and management of plastic bronchitis among adults

Plastic bronchitis is a rare, underdiagnosed and potentially fatal condition. It is characterised by the formation and expectoration of branching gelatinous plugs that assume the shape of the airways. These airway plugs differ from the allergic mucin that characterises allergic bronchopulmonary aspergillosis and mucoid impaction of the bronchi. Plastic bronchitis is most often encountered in the paediatric population following corrective cardiac surgery, such as the Fontan procedure. It also occurs in adults. Plastic bronchitis in adults is rare, heterogeneous in its aetiology, and can lead to respiratory distress or even life-threatening airway obstruction. Plastic bronchitis in adulthood should not be overlooked, particularly in patients with chronic inflammatory lung diseases. This review presents current understanding of the presentation, aetiology, pathogenesis, pathology and management of plastic bronchitis in adults.

Fungal Sinusitis

Fungal sinusitis encompasses a spectrum of fungal disease processes affecting the paranasal sinuses, ranging from asymptomatic colonization to rapidly progressive and fatal infections. This review contains 10 figures, 3 tables, and 30 references. Key Words: fungal sinusitis, mycetoma, allergic fungal rhinosinusitis, invasive fungal sinusitis, mucormycosis, allergic mucin

Prevalence of allergic fungal sinusitis among patients with nasal polyposis

Objective: The objectives of the study were to determine the frequency of AFS among patients with nasal polyps and to compare the Lund-Mackay scores of patients with and without AFS. Methods: The study was carried out at a tertiary health care center of Karachi, Pakistan from December 2016 to November 2018, after taking ethical approval. Total of 114 patients with sinonasal polyposis undergoing surgery were included. Patients were categorized as case of AFS when histopathology showed allergic mucin with fungal hyphae and culture was positive for fungal growth. Lund-Mackay scoring based on CT PNS of each patient was done and mean scores of AFS and non AFS patients were compared. Results: Mean age of 114 participants was 37.3 ± 15.3 years. 61 (53.5%) of them were males. 27 (23.7%) patients met the AFS criteria. 19 (16.7%) patients were asthmatic and a significant relationship was found between asthma and AFS (P = 0.03). The mean Lund-Mackay score was 13.2 for non AFS and 18.8 for AFS patients (P = <0.01). Recurrence was seen in 11 (9.6%) cases. Conclusion: The frequency of AFS in patients with nasal polyps was 23.7% and the patients with AFS showed significantly higher mean Lund-Mackay score compared to non AFS patients. Continuous....

Allergic Fungal rhino-sinusitis frequency in chronic rhino-sinusitis patients and accuracy of fungal culture in its diagnosis

Objective: To determine the frequency of Allergic Fungal Rhino-sinusitis (AFRS) in Chronic Rhino-sinusitis (CRS) patients and the accuracy of fungal culture in diagnosing AFRS. Methods: Immunocompetent patients with CRS and without invasive fungal rhino-sinusitis presenting over a period of 3 years in ENT department of Mayo Hospital, from April 2014 to September 2017 were included in the study. AFRS was diagnosed clinically and on Bent and Kuhn diagnostic criteria. All patients underwent endoscopic sinus surgery. Removed tissue histopathology and fungal culture was done. Diagnostic accuracy of fungal culture in AFRS patients was determined. Results: Out of 216 patients of CRS, 45 (20.8%) had AFRS. Mean age of patients diagnosed with AFRS was 29.49±9.16. Out of 45 patients, 26 were male and 19 were female. Nasal polyps were present in 45 (100%) patients, fungal stain was positive in 39(86.7%). CT scan showed sinus expansion in 28(62.2%) patients, heterogeneous opacity in 45(100%) patients and bone destruction in 13(28.9%). Presence of Allergic Mucin was seen in 45(100%) patients, high IgE levels in 36(80.0%), eosinophilia in 21(46.7%), presence of Charcot Leyden crystals in 27(60.0%). Asymmetrical involvement of sinuses was seen in 30 (66.7%) and co-existent asthma was seen in 18(40.0%). Fungal culture positive patients were 25(55.6%). Diagnostic accuracy of fungal culture was 91.6%. Conclusion: Fungal culture has a key role in confirming diagnosis of AFRS. We also noted that frequency of AFRS is increasing in CRS patients. doi: https://doi.org/10.12669/pjms.36.3.1661 How to cite this:Awan NU, Cheema KM, Naumeri F, Qamar S. Allergic Fungal rhino-sinusitis frequency in chronic rhino-sinusitis patients and accuracy of fungal culture in its diagnosis. Pak J Med Sci. 2020;36(3):---------. doi: https://doi.org/10.12669/pjms.36.3.1661 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Radiographic Nuances in Allergic Fungal Rhinosinusitis

Background Allergic fungal rhinosinusitis (AFRS) is characterized by higher revision endoscopic sinus surgery (ESS) rates and unique radiographic features when compared to chronic rhinosinusitis with nasal polyposis (CRSwNP) or chronic rhinosinusitis without nasal polyposis (CRSsNP). Objective We hypothesized that an increased frequency of concha bullosa in AFRS or other radiographic nuances might allow for accumulation of allergic mucin and contribute to increased ESS revision rates. Methods A retrospective cohort study was performed. Patient diagnosis (AFRS, CRSwNP, and CRSsNP), basic demographics, and prior ESS rates were collected. Results A total of 210 consecutive patients were included (AFRS = 70, CRSwNP = 70, and CRSsNP = 70). Pediatric AFRS patients had more unilateral disease (38.1% vs 4.4%; P = .007) and anterior ethmoid skull base erosion (23.8% vs 6.7%; P = .047) than adult AFRS patients. AFRS patients were more likely to be younger (24.9 ± 10.1 years vs 45.6 ± 14.4 years vs 48.7 ± 18.2 years; P < .001), African American (70% vs 14.3% vs 11.4%; P < .001), and have undergone prior ESS (54.3% vs 45.7% vs 31.4%; P = .02) than CRSwNP or CRSsNP patients. Concha bullosa were more prevalent in AFRS patients than CRSwNP or CRSsNP patients across the population (42.9%, 18.6%, and 14.3%; P < .001) and in the setting of no previous surgery (53.1%, 31.6%, and 16.7%; P < .001). Conclusion In this cohort, pediatric AFRS patients had more unilateral disease and anterior ethmoid skull base erosion. Concha bullosa prevalence was significantly higher in AFRS as compared to those with CRSwNP or CRSsNP, despite prior ESS. Surgeons should consider concha bullosa as a potential anatomical subsite to harbor recurrent or residual disease.

Low Incidence of Allergic Fungal Rhinosinusitis in Japanese Patients

Background: Allergic fungal rhinosinusitis (AFRS) is a noninvasive fungal disease of the sinuses with a very high recurrence rate. A very small number of Japanese cases have been reported. Material and methods: The subjects were 6 patients with AFRS out of 429 patients who underwent endoscopic sinus surgery at Kagawa Rosai Hospital between December 2011 and November 2017. We retrospectively examined the clinical features and outcomes of these 6 patients. Results: The incidence of AFRS was 1.4% (6/429). Allergic fungal rhinosinusitis was unilateral in 5 cases and bilateral in 1. Computed tomography revealed hyperdense areas representing allergic mucin, but no patient exhibited bone erosion. Magnetic resonance imaging showed hypointense or no signal regions at the locations of allergic mucin. Postoperatively, 1 patient developed recurrence. Because the recurrent patient had no significant symptoms, he refused further surgery and received drug therapy. Preoperative eosinophil counts and total IgE levels were elevated in all patients; postoperatively, both remained high in the patient who developed recurrence. Postoperative treatments included steroid therapy and nasal irrigation. Conclusions: Allergic fungal rhinosinusitis is less prevalent in Japan than in Western nations. Peripheral blood eosinophil and serum IgE values may be used as the biomarkers. Significance: Allergic fungal rhinosinusitis is prone to recurrence. Postoperative treatment including steroid therapy is important in the management of AFRS.