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Clinical Problem Solving: Radiology
March 15, 2010

Radiology Quiz Case 2: Diagnosis

Author Affiliations
 

C. DOUGLASPHILLIPSMD

Arch Otolaryngol Head Neck Surg. 2010;136(3):308-309. doi:10.1001/archoto.2010.11-b

Allergic fungal rhinosinusitis was first reported in the early 1980s as an emerging form of chronic noninvasive fungal sinus disease. The pathogenesis of this disorder is thought to be IgE-mediated hypersensitivity to inhaled fungal antigens, resulting in a chronic, noninfectious, inflammatory process.1The disease is estimated to affect 5% to 10% of all patients with chronic rhinosinusitis who undergo sinus surgery.1,2It is the most common type of fungal sinusitis worldwide and is particularly seen in warm, humid climates.1,3Patients affected with AFRS tend to be younger (usually in the third decade of life), immunocompetent, and atopic, with an associated history of asthma, aspirin sensitivity, allergic rhinitis, or nasal polyposis.14They also tend to present with slowly progressive, typically unilateral symptoms of nasal congestion and obstruction, headaches, anosmia, and copious rhinorrhea or postnasal drainage.1,3,4Many patients report a long-standing history of sinus-related complaints that have persisted despite maximal medical therapy and previous sinus operations.1,3,4In severe cases, ophthalmic symptoms and signs, including visual deficits, may manifest.5The most commonly reported ophthalmic symptom is diplopia, while the most common sign is orbital proptosis.3Though still controversial, the most widely accepted diagnostic criteria for AFRS currently include the following: type 1, IgE-mediated hypersensitivity to fungi; nasal polyposis; characteristic CT (or MRI) findings; presence of eosinophils in nasal secretions; no evidence of invasion of the mucosal lining of the sinus by fungal elements; and a positive surgical sinus fungal culture.24Other studies that may help diagnose AFRS include determination of serum IgE and fungal-specific IgG levels, which can be elevated during acute flare-ups.4,6

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