PI-06. Surgical experience in the treatment of invasive fungal disease of upper respiratory tract in hematological patients and patients who have a new coronavirus infection caused by SARS-CoV-2

Summary

In recent decades, there has been an increase in patients with invasive mycoses (MI) of the upper respiratory ways. This trend is due to increased numbers of patients with various risk factors, e.g., immunodeficiencies caused by prolonged use of glucocorticoids (GCS) and other immunosuppressive drugs in oncological and hematological diseases, allogeneic hematopoietic stem cell transplantation (allo-HSCT) followed by graft-versus-host disease (GVHD), HIV infection, prolonged massive antibacterial therapy, diabetes mellitus, bronchial asthma, prolonged staying at the intensive care units etc. Currently, higher MI occurrence may be assigned to pandemic of the new SARS-CoV-2 infection, secondary immunodeficiency conditions due to COVID-19 and its treatment. The purpose of the work was to study the features of risk groups, specific endoscopic and X-ray patterns in different lesions of nasal cavity and paranasal sinuses caused by various pathogens in the invasive mycoses, as well as to evaluate efficiency and features of surgical treatment in immunocompromised patients with sinus-orbital form of the disease.

Patients and method

Clinical analysis included 9 cases with IM observed at the R. M. Gorbacheva Research Institute (7 hematological patients over 2018 to 2021), as well as two patients who underwent COVID-19, treated at the Department of Otorhinolaryngology (Pavlov University) in 2021.

Results

The patients with MI had different background disorders, e.g., agranulocytosis after antitumor chemotherapy for acute leukemia (n=4), allo-HSCT (n=2) performed, resp., for acute leukemia and Hurler syndrome, and drug-induced hapten agranulocytosis (n=1), as well as usage of GCS for the COVID-19 treatment (n=2). The group included 3 males and 6 females at the age of 1.7 to 80 years, 3 children (33.3%) and 6 adults (66.7%). The main clinical manifestations of MI affecting upper respiratory tract were as follows: fever reaction >38°C (78%, only in hematological patients), nasal breathing disorder (100%), local hyperemia and facial edema (78%), pain/pressure and feeling of overflow in the facial area (78%), headache (44%), ptosis (22%), ophthalmoplegia (11%). Diagnosis of MI in 100% of patients included computed tomography (CT) of the paranasal sinuses, endoscopic examination, biopsy, direct microscopy, cultural examination of the biopsy. CT signs of MI included decreased pneumatization of sinuses (100%), destruction of bone tissue (78%). Sufficient lesions were revealed by endoscopy, i.e., necrosis of the mucous membrane (88.9%), destruction of bone structures (77.8%). The diagnosis of MI was established using microscopy with calcofluor staining of biopsy specimens (100%). Mycological studies in MI patients have revealed mucormycosis (n=4), fusariosis (n=2), aspergillosis (n=2), a combination of mucormycosis and aspergillosis (n=1). The patients received systemic antifungal therapy in accordance with international guidelines. Surgical treatment was performed in 100% of patients with mucormycosis and fusariosis as emergent care. Surgery in aspergillosis was carried out upon restoration of hematopoiesis.

Conclusion

Immunocompromised patients are at increased risk for development of invasive mycoses. Extremely rapid spread is a typical feature of MI, with development of significant lesions, e.g., tissue necrosis, destruction, bleeding, penetration into the orbit, or cranial cavity. The key efforts include early drug therapy and surgical intervention which is determined by a specific pathogen.

Keywords

Invasive mycosis, immunosuppression, oncohematological group, graft-versus-host disease.