R Lin, M Aziz, H Yoo-Bowne
R Lin, M Aziz, H Yoo-Bowne. Maxillary Sinus Mycetoma Associated With Hypersensitivity To Mucor Racemosus. The Internet Journal of Asthma, Allergy and Immunology. 2005 Volume 5 Number 1.
Mold hypersensitivity may play a role in chronic sinusitis. Although mucor has been identified in allergic fungal sinusitis, to our knowledge this is the first reported case of mucor associated mycetoma in association with immediate hypersensitivity to mucor.
In the beginning of 2005, a 39 year old Chinese male presented to the St Vincents Hospital otolaryngology clinic with a 10 year history of nasal congestion with the left side of the nose being more affected. He had a nasal operation in 1996 in China, the country of his birth. His work experience included working in a bread factory in China. He immigrated to the United States in 2003. En route, he was allergy tested in Japan where he was told that he had many allergies. The patient also complained of a foul smell in his nose and occasional yellowish discharge from the left side of his nose. The patient denied other medical problems including diabetes, immunodeficiencies, and asthma. On endoscopy an enlarged left uncinate process, and polypoid tissue in the area of the left osteomeatal complex were noted. The patient was treated with mometasone nasal spray, oral loratadine, and amoxacillin/clavulinate without any improvement in symptoms. A maxillofacial CT scan showed extensive left maxillary sinus disease. Soft tissue density was noted in the left maxillary sinus with higher density areas within. There was widening of the left osteomeatal complex (Figure 1).
The other paranasal sinuses were normal. A complete blood count, basic blood chemistries, and liver panel were within normal limits. There was no increase in blood eosinophils. In March 2005, the patient underwent sinus surgery where a left antrostomy/uncinectomy and left maxillary sinus evacuation were performed. The contents in the maxillary sinus consisted of yellowish to greenish, inspissated mucoid material. Tissue specimens revealed inflammation with some eosinophil infiltration but no eosinophilic staining mucin. There was also some tissue necrosis, and presence of fungal hyphae collections(Figure 2 GMS fungal stain. Original magnification X40).
Fungal cultures however revealed no growth. Post-operatively the patient was evaluated for aero-allergies. The total IgE was 83 IU/mL. Specific IgE was present for several common pollens including orchard grass, common ragweed, birch, maple, pecan tree, white ash, and oak. All allergen specific IgE levels were greater than 1 kIU/mL as determined by the Immunocap ™ method. A lower amount of specific IgE(0.46 kIU/mL) to
Sinus mycetomas are considered a non-invasive form of fungal sinusitis(1). They are usually not associated with immunosuppressed hosts. The most common causes are
Although mold allergy studies has not been extensively studied in China, at least one report(7) finds that prevalence of similar mold spores such as those that are prevalent in other Western countries including
Allergic mucin in response to fungi are felt to be an essential diagnostic feature in allergic fungal sinusitis(2). Allergic mucin was not observed in the herein described patient. It is conceivable that this patient had an incomplete form of allergic fungal sinusitis, despite not having allergic mucin, or sheets of eosinophils which are commonly described in allergic fungal sinusitis. The diagnostic criteria for allergic fungal sinusitis may be evolving(8).
Mold hypersensitivity may also play a role in chronic sinusitis(9). Although mucor has been identified in allergic fungal sinusitis(10), to our knowledge this is the first reported case of mucor associated mycetoma in association with immediate hypersensitivity to mucor.