Zusammenfassung
Hintergrund: Akute invasive und fulminant verlaufende Pilzsinusitiden sind seltene Komplikationen,
die zu lebensbedrohenden Komplikationen führen können. Betroffen sind in erster Linie
immunsupprimierte Patienten. Die Zunahme der opportunistischen systemischen Mykosen
führt auch dazu, dass der HNO-Arzt in seiner stationären und Konsiliartätigkeit zunehmend
mit diesen Fällen und Fragestellungen zur operativen Intervention konfrontiert wird.
Patienten: Wir berichten exemplarisch über 2 Fälle einer invasiven und fulminant verlaufenden
Aspergillose der Nasennebenhöhlen bei Immunsuppression. Trotz systemischer antimykotischer
und operativer Therapie kam es in beiden Fällen zu intrakraniellen und zum Teil systemischen
Komplikationen mit letalem Verlauf. Schlussfolgerungen: Bei immunsupprimierten Patienten muss an eine invasive Pilzsinusitis gedacht werden,
wenn periorbitale Entzündungszeichen, einseitige Transparenzminderungen der Nasennebenhöhlen
und Knochenarrosionen nachweisbar sind. Dabei spielen pathogene Aspergillusspezies
eine vordergründige Rolle. Die in vielen Fällen letal verlaufende Erkrankung einer
akuten invasiven Pilzsinusitis fordert eine schnelle Diagnostik und Therapie sowie
interdisziplinäre Kooperation. Ob und wann eine limitierte oder ausgedehnte chirurgische
Intervention erfolgen soll, bleibt aufgrund der Seltenheit dieses Krankheitsbildes
und der geringen Erfahrungen mit dieser Erkrankung noch immer ein kontrovers diskutiertes
Problem. Indikation und Prognose werden entscheidend von der Grunderkrankung, der
Immunitätslage, der speziellen Form der invasiven Pilzsinusitis und dem Grad der Gewebsinvasion
bestimmt.
Acute and Fulminant Fungal Sinusitis in Immunosuppressed Patients
Background: Acute and invasive fungal sinusitis represent rare diseases which can lead to life
threatening complications. Immunosuppressed patients are affected primarily. The expansion
of transplantation medicine and the progress in therapy of malignant diseases of the
lymphatic system are associated with an increase of opportunistic systemic mycoses.
Therefore the otorhinolaryngologist is confronted increasingly with these problems
and questions for surgery, especially if the symptom of a periorbital inflammation
occurs as a sign for a beginning orbital complication and radiological signs of involvement
of the paranasal sinuses exist. Patients: We report exemplary about two immunosuppressed patients with an invasive and fulminant
fungal aspergillosis of the paranasal sinuses. In spite of systemic antifungal therapy
and surgical intervention, intracranial and systemic complications caused a lethal
course. Conclusions: In immunosuppressed patients with clinical and radiological signs for a sinusitis
and a periorbital inflammation an invasive fungal sinusitis should be considered.
Pathogenic aspergillus species are the most common identified in fungal sinusitis.
The disease with often lethal outcome requires a careful and fast diagnostic and therapy
as well as interdisciplinary cooperation. If and when limited or extensive surgery
should be performed remains, because of the rarity and the lacking experience with
this disease, still a controversially discussed issue and depends on several factors:
the kind of disease, the immunity, the subtype of invasive fungal sinusitis and the
degree of tissue invasion.
Schlüsselwörter:
Fulminant - Sinusitis - Mykose - Aspergillose - Immunsuppression
Key words:
Fulminant - Sinusitis - Fungal - Aspergillosis - Immunosuppression
Literatur
- 1
Kennedy C A, Adams G L, Neglia J P, Giebink G S.
Impact of surgical treatment on paranasal fungal infections in bone marrow transplant
patients.
Otolaryngol Head Neck Surg.
1997;
116
610-616
- 2
Antoine G A, Gates R H, Park A O.
Invasive aspergillosis in a patient with aplastic anemia receiving amphotericin B.
Head Neck Surg.
1988;
10
199-203
- 3
Stammberger H, Jakse R.
Aspergillus-Mykosen im HNO-Bereich.
HNO.
1982;
30
81-87
- 4
Stammberger H.
Zur Entstehung röntgendichter Strukturen bei Aspergillus-Mykosen der Nasennebenhöhlen.
HNO.
1985;
33
62-64
- 5
Katzenstein A L, Sale S R, Greenberger P A.
Allergic Aspergillus sinusitis: a newly recognized form of sinusitis.
J Allergy Clin Immunol.
1983;
72
89-93
- 6
Robson J M, Hogan P G, Benn R A, Gatenby P A.
Allergic fungal sinusitis presenting as a paranasal sinus tumour.
Aust N Z J Med.
1989;
19
351-353
- 7
Baker R D.
Leukopenia and therapy in leukemia as factors predisposing to fatal mycosis.
Am J Clin Pathol.
1962;
37
358-373
- 8
Hora J F.
Primary Aspergillosis of the paranasal sinuses and associated areas.
Laryngoscope.
1965;
75
768-773
- 9
Zapater E, Armengot M, Campos A, Montalt J, Pedro F, Basterra J.
Invasive fungal sinusitis in immunosuppressed patients. Report of three cases.
Acta Otorhinolaryngol Belg.
1996;
50
137-142
- 10
Ponikau J U, Sherris A D, Kern E B, Homburger H A, Frigas E, Gaffey T A, Roberts G D.
The diagnosis and incidence of allergic fungal sinusitis.
Mayo Clin Proc.
1999;
74
877-884
- 11
DeShazo R D, Chapin K, Swain R E.
Fungal sinusitis.
N Engl J Med.
1997;
337
254-259
- 12
Framme C, Rosenfeld J, Sachs H G.
Invasive Aspergillose mit Orbitabefall unter Immunkompetenz.
Ophthalmologe.
2000;
97
280-284
- 13
Streppel M, Bachmann G, Arnold G, Damm M, Stennert E.
Successful treatment of an invasive aspergillosis of the skull base and paranasal
sinuses with liposomal amphotericin B and itraconazole.
Ann Otol Rhinol Laryngol.
1999;
108
205-207
- 14
Garcia-Asensio S, Artigas J M, Barrena R.
Optic nerve aspergillosis: report of a case diagnosed by fine needle aspiration biopsy.
Eur Radiol.
2000;
10
573-575
- 15
Chandra S, Goyal M, Mishra N K, Gaikwad S B.
Invasive aspergillosis persenting as a cavernous sinus mass in immuno competent individuals;
report of 3 cases.
Neuroradiology.
2000;
42
108-111
- 16
Mc Gill T J, Simpson G, Healy G B.
Fulminant aspergillosis of the nose and paranasal sinuses: a new clinical entity.
Laryngoscope.
1980;
90
748-754
- 17
Verschraegen C F, van Besien K W, Dignani C, Hester J P, Anderson B S, Anaissie E.
Invasive aspergillus sinusitis during bone marrow transplantation.
Scand J Infect Dis.
1997;
29
436-438
- 18
Rowe-Jones J.
Paranasal aspergillosis - a spectrum of disease (editorial).
J Laryngol Otol.
1993;
107
773-774
- 19
Schwartz R S, Mackintosh F R, Schrier S L, Greenberg P L.
Multivariante analysis of factors associated with invasive fungal disease during remission
induction therapy for acute myelogenous leukemia.
Cancer.
1984;
53
411-419
- 20
Viollier A F, Peterson D E, de Jongh C A, Newman K A, Gray W C, Sutherland J C, Moody M A,
Schimpff S C.
Aspergillus sinusitis in cancer patients.
Cancer.
1986;
58
366-371
- 21
Schubert M M, Peterson D E, Meyers J D, Hackman R, Thomas E D.
Head and neck aspergillosis in patients undergoing bone marrow transplantation.
Cancer.
1984;
57
1092-1096
- 22
Drakos P E, Nagler A, Or R, Naparstek E, Kapelushnik J, Engelhard D, Rahav G, Ne'emean D E,
Slavin S.
Invasive fungal sinusitis in patients undergoing bone marrow transplantation.
Bone Marrow Transplant.
1993;
12
203-208
- 23
Johnson T E, Casiano R R, Kronish J W, Tse D T, Meldrum M, Chang W.
Sino-orbital aspergillosis in acquired immunodeficiency syndrom.
Arch Ophthalmol.
1999;
117
57-64
- 24
Lowe J, Bradley J.
Cerebral and orbital aspergillus infection due to invasive aspergillosis. J.
Clin Pathol.
1986;
39
774-778
- 25
Rogers T R, Haynes K A, Barnes T R.
Value of antigen detection in predicting invasive pulmonary aspergillosis.
The Lancet.
1990;
336
1210-1213
- 26
Denning D W, Stevens D A.
Antifungal and surgical treatment of invasive aspergillosis: review of 2121 published
cases.
Rec Infect Dis.
1990;
12
1147-1201
- 27
Landoy Z, Rotstein C, Shedd D.
Aspergillosis of the nose and paranasal sinuses in neutropenic patients at an oncology
center.
Head Neck Surg.
1985;
8
83-90
- 28
Chang T, Teng M MH, Wang S F, Li W Y, Cheng C C, Lirng J F.
Aspergillosis of the paranasal sinuses.
Neuroradiology.
1992;
34
520-523
- 29
De Foer C, Fossion E, Vaillant J M.
Sinus aspergillosis.
J Craniomaxillofac Surg.
1990;
18
33-40
- 30
Yumoto E, Kitani S, Okumara H.
Sino-orbital aspergillosis associated with total ophthalmoplagia.
Laryngoscope.
1985;
95
190-192
- 31
Ponikau J, Wolf E, Groden C, Koch U.
Invasive Pilzsinusitis.
Otorhinolaryngol Nova.
1996;
6
250-256
- 32
Berkow R L, Weisman S J, Provisor A J, Weetman R M, Baehner R L.
Invasive aspergillosis of paranasal tissues in children with malignancies.
J Pediatr.
1983;
103
49-53
- 33
Streppel M, Stennert E, Lackner K J, Eckel H E, Arnold G.
Medikamentöse Behandlung der invasiven Aspergillose der Nasennebenhöhlen.
Laryngo-Rhino-Otol.
1997;
76
19-22
- 34
Naim-Ur-Rahman , Jamjoom A, Al-Hedaithy S A, Jamjoom Z AB, Al-Sohaibani M O, Aziz S A.
Cranial and intracranial aspergillosis of sinunasal origin.
Acta Neurochir (Wien).
1996;
138
944-950
Dr. med. Leif Erik Walther
Universitäts-HNO-Klinik
Friedrich-Schiller-Universität Jena
Lessingstraße 2
07740 Jena
Email: E-mail: Leif.Walther@med.uni-jena.de