Maruf Maheen, Loya Asif, Mushtaq Sajid, Hassan Usman, Hussain Mudassar, Hameed Maryam
Histopathology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK.
Cureus. 2023 Jul 15;15(7):e41915. doi: 10.7759/cureus.41915. eCollection 2023 Jul.
Fungal rhinosinusitis (FRS) is a relatively common, but often misdiagnosed disease of paranasal sinuses. The FRS is classified into invasive and non-invasive forms. The non-invasive form includes fungal ball and allergic FRS, and invasive form includes acute invasive FRS, chronic invasive FRS, and granulomatous FRS. Invasive fungal infections are associated with high morbidity and mortality, hence requiring urgent medical and surgical intervention. The histomorphology can help identify certain fungal organisms that cannot be cultured or are rarely visible in exudates. The morphologic diagnosis of tissue invasive and non-invasive fungal infection is essential for appropriate treatment. We analyzed cases of rhinosinusitis from 2017 to 2019 in Pathology Department at a tertiary care cancer hospital, Lahore, Pakistan. All clinical information was retrieved from patient records. Paraffin-embedded tissue blocks were stained with hematoxylin and eosin (H&E), special Grocott methenamine silver stain (GMS), and periodic acid Schiff stain (PAS) according to standard protocol. They were reviewed by two pathologists blinded by fungus status. A total of 169 cases of rhinosinusitis were reviewed. FRS comprised 146 (86.4%) of them. The mean age of patients with FRS was 32.8±14 years. The male:female ratio was 1.4:1. Maxillary sinus was the main site of involvement in 39 (27%) FRS cases. Aspergillus was identified in 117 (80.1%) cases of FRS. The culture reports were available in 44/146 (30.14%) FRS cases. They were negative in 22/44 (50.0%), and Aspergillus species were isolated in 18/44 (40.9%) cases of FRS. There were 84 (57.5%) cases of non-invasive FRS and 59 (40.4%) cases of invasive FRS. Among invasive FRS, there were 56 (38.4%) chronic granulomatous FRS cases including mixed patterns. Majority cases, 54 (96.4%), of chronic granulomatous FRS showed a unique crowded giant cell pattern comprising of foreign body and Langhans type giant cells. These giant cells were arranged closely forming irregular non-caseating granulomas surrounded by lymphocytes and fibrosis. Interestingly, the giant cells were scattered haphazardly without forming a granuloma as well. Fungal organisms were identified in all 56 cases of chronic granulomatous FRS. Histologically, predominant organism was Aspergillus in 48 (85.7%) on GMS and PAS stain. Our study observed a unique crowded giant cell pattern, which is a hallmark of invasive fungal infection. If pathologists are familiar with this unique pattern, they can make a quick and accurate diagnosis on histology. The physician can start antifungal treatment timely for better prognosis.
真菌性鼻窦炎（FRS）是一种相对常见但常被误诊的鼻窦疾病。FRS分为侵袭性和非侵袭性两种类型。非侵袭性类型包括真菌球和变应性FRS，侵袭性类型包括急性侵袭性FRS、慢性侵袭性FRS和肉芽肿性FRS。侵袭性真菌感染与高发病率和死亡率相关，因此需要紧急的药物和手术干预。组织形态学有助于识别某些无法培养或在渗出物中很少可见的真菌生物。组织侵袭性和非侵袭性真菌感染的形态学诊断对于恰当治疗至关重要。我们分析了巴基斯坦拉合尔一家三级癌症专科医院病理科2017年至2019年的鼻窦炎病例。所有临床信息均从患者记录中获取。根据标准方案，将石蜡包埋的组织块用苏木精和伊红（H&E）、特殊的格罗科特六胺银染色（GMS）和过碘酸希夫染色（PAS）进行染色。由两名对真菌状态不知情的病理学家进行复查。共复查了169例鼻窦炎病例。其中FRS有146例（86.4%）。FRS患者的平均年龄为32.8±14岁。男女比例为1.4:1。上颌窦是39例（27%）FRS病例的主要受累部位。在117例（80.1%）FRS病例中鉴定出曲霉菌。146例FRS病例中有44例（30.14%）有培养报告。其中22/44例（50.0%）为阴性，18/44例（40.9%）FRS病例分离出曲霉菌属。有84例（57.5%）非侵袭性FRS病例和59例（40.4%）侵袭性FRS病例。在侵袭性FRS中，有56例（38.4%）慢性肉芽肿性FRS病例，包括混合模式。大多数慢性肉芽肿性FRS病例，54例（96.4%），表现出一种独特的密集巨细胞模式，由异物型和朗汉斯型巨细胞组成。这些巨细胞紧密排列形成不规则的非干酪样肉芽肿，周围有淋巴细胞和纤维化。有趣的是，巨细胞也随机散在分布而不形成肉芽肿。在所有56例慢性肉芽肿性FRS病例中均鉴定出真菌生物。组织学上，在GMS和PAS染色中，48例（85.7%）主要真菌为曲霉菌。我们的研究观察到一种独特的密集巨细胞模式，这是侵袭性真菌感染的一个标志。如果病理学家熟悉这种独特模式，他们可以在组织学上做出快速准确的诊断。医生可以及时开始抗真菌治疗以获得更好的预后。
