Portuguese Version

Year:  2002  Vol. 68   Ed. 5 - (9º)

Artigo Original

Pages: 654 to 661

PDF PT  

Fungal research in 20 patientes with nasal polyposis

Author(s): Carla R. Monteiro 1,
Alfeu T. França 2,
Eliana B. Bergter 3,
Márcia R. Pinto 4,
Solange O. R. Valle 5,
Fernando A. Rodrigues 6

Keywords: nasal polyposis, allergy, Aspergillus, Candida, fungal infection.

Abstract:
Introduction: Nasal polyposis is a frequent disease in the otolaryngology clinical practice. The association of this disease with fungi has been receiving more attention only in the last 20 years, mainly after the recognition of Allergic Fungal Sinusitis. Aim: The objective is to identify fungal elements in the sinus of patientes with nasal polyposis and to analyze their immunologic responses to aeroalergens. Study Design: clinical prospective. Material and Method: We analyzed in a prospective way, 20 patients with the diagnose of sinonasal polyposis, who presented themselves at the Otolaringology ambulatory of the "Hospital Universitário Clementino Fraga Filho". During the surgical treatment, the specimens removed from the paranasal sinuses, were placed in flasks containing Sabouraud with chloramphenicol. Following this procedure, the samples were sent for hystologic analysis and culture. Total IgE, specific IgE to Aspergillus fumigatus serum levels and eosinophilis count were dosed. The patients were also submitted to cutaneous tests with Dermatophagoides pteronyssinus, Dermatophagoides farinae, Blomia tropicalis, Blattella germanica, Blattella americana and Aspergillus fumigatus antigens. Results: Six patients (30%) showed fungal development, i.e. 4 Aspergillus sp, 1 Candida tropicalis and 1 Cladophialophora carrionii. Thirteen (68,42%) had positive prick test for the antigens described above. Ten patients (50%) showed eosinophilia. High serum levels of total IgE were found in eight (44.4%). The increased IgE-specific serum levels to Aspergillus fumigatus were observed in only one patient. Conclusion: We want to emphasize the relevance of the fungi research and of the immune system investigation in patients with nasal polyposis, aiming a more accurate diagnose and an adequate treatment.

INTRODUCTION

Nasosinusal polyposis (NP) and fungal infection of paranasal sinuses are nosological entities found in routine clinical Otorhinolaryngology.

NP can be defined as a chronic inflammatory process of the nose and paranasal sinuses mucosa, bilateral, with multifocal edematous transformation that leads to protrusion of benign polyps originating from the meatus towards the nasal cavity1, 2. Most of the time, the patients with NP present one or more affected paranasal sinuses and symptoms of chronic rhinosinusitis. The true pathophysiology of the disease is still obscure. The diagnosis of NP, after anamnesis, clinical examination and endoscopic exam is confirmed by histopathologic analysis of the lesion.

The diagnosis of fungal sinusitis (FS), however, requires a high level of suspicion by the physician, since the clinical examination is rarely conclusive. In order to confirm the suspicion, the identification of the fungus can be made by culture collected from the material and/or histopathology. This is exactly the most critical point of diagnosis - to confirm the fungal elements in the paranasal sinuses collected material. In past years, thanks to the more detailed nasosinusal mucosa analysis and the development of better techniques for isolation of fungi, it became possible to classify FS in four types: acute/fulminating, chronic/indolent; fungal ball and allergic fungal sinusitis (AFS)3, 4, 5. This classification is based on presence or absence of tissue invasion, as well as immune status of the patient.

The correlation between NP and fungal infections of paranasal sinuses has been a topic for research and investigation in various centers of the world.

Chhabra et al.6, after an analysis of 28 consecutive cases of NP, isolated the paranasal sinuses fungi in 11 patients. According to Cody et al.7, 10 to 20% of the patients with chronic sinusitis that are submitted to surgery have fungi as the main etiological agent. Goldstein in 19948 recorded an incidence of 66% of NP among patients with AFS. Araujo et al.9 after the prospective assessment of 708 patients with chronic sinusitis submitted to functional endoscopic sinus surgery identified AFS in 11 (1.5%). Among them, 6 had bronchial asthma and 10 had NP.

The interest for the topic increased mainly after the recognition of a new modality of FS, named allergic fungal sinusitis, in the beginning of the 80's10. In this type of FS, the presence of nasal polyps is considered one of the main criteria for the diagnosis5, 11. DeShazo in 199712 stated that "AFS should be suspected in patients with atopia, chronic sinusitis and nasal polyposis". In view of that, we studied prospectively 20 patients with NP and the objectives of the study were:

 To identify the fungus(I) in material collected from the paranasal sinuses;
 To analyze the reactivity of these patients to aeroallergens, using skin tests, serum dosages of Immunoglobulin E (IgE) both total and specific for Aspergillus fumigatus (Af) and eosinophil count in peripheral blood.

MATERIAL AND METHOD

We conducted a prospective descriptive study involving 20 patients with NP that came to be treated at the Ambulatory of Otorhinolaryngology and Clinical Immunology at University Hospital Clementino Fraga Filho (HUCFF), Federal University of Rio de Janeiro (UFRJ). Data were collected between June 1998 and October 2000.

We included patients of both genders, immunocompetent with no limits of age, race or social class.
We excluded patients with infectious diseases in activity, hematological affections, secondary immunodeficiencies and diabetes mellitus, diseases in which the fungus can act in an aggressive and invasive way.

The research project and its informed consent term had been analyzed and approved by the Research Ethics Committee of HUCFF, project application No. 055/00. All patients agreed to participate by signing the informed consent term.

In addition to surgery, we conducted cutaneous tests (puncture test - PT) with inhalation antigens and Af, serum doses of total IgE, Af-specific IgE and eosinophil count in peripheral blood. The inhalation antigens used were: Dermatophagoides pteronyssinus, Dermatophagoides farinae, Blomia tropicalis, Blattella germanica, Blattella americana and Af. Positive and negative controls were conducted. The adopted classification for interpretation of the prick test were those of the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology, which consider as positive tests whose papule is equal or greater than 3 millimeters in transversal diameter, without reaction on the negative control site. The test was conducted in 19 patients.

The dose of total serum IgE was made using immunonephelometry method (BN II device) and the values obtained were expressed in International Units per milliliter (IU/ml) and classified according to the normal standard, defined based on age of patient. The test was conducted in 18 patients.

Serum dosage of Af-specific IgE was made using the immunofluoroenzymatic automated method in UniCAP device, by Pharmacia & Upjohn. The values obtained were expressed in UI/ml. This test was conducted in 13 patients.

Eosinophil counts in peripheral blood were conducted at the Clinical Pathology Lab of Hematology at HUCFF, considered eosinophilia when the values were above 350cells/mm3 or 5%.

All patients had surgical indication and underwent removal of nasal polyps. Materials (secretion and/or polyps), collected from the affected paranasal sinus, were placed immediately in a flask that contained Sabouraud culture medium with chloramphenicol and sent to the Laboratory of Chemical Biology of Microorganism (LQBM), Professor Eliana Barreto Bergter, from the Department of General Microbiology, Institute of Microbiology, UFRJ. Three cultures were analyzed by Laboratório de Coleção de Cultura de Fungos - IOC- FioCruz.

Histopathology exam of the material was necessary to identify the elements that characterize chronic rhinosinusitis and allergic mucin, as well as to rule out invasive fungal affections. This analysis was conducted in all patients.

The patients were divided into 2 groups. One had patients with positive culture and the other with negative culture, comparing the following variables:

1. Mean age of patients;
2. Proportion between male and female subjects;
3. Presence of comorbidities, including asthma, intolerance to non-steroidal antiinflammatory drugs (NSAID);
4. Previous nasal and sinusal surgeries;
5. Serum dosage of total IgE and Af-specific IgE;
6. Eosinophil count in peripheral blood;
7. PT with the aeroallergens referred above.

All information collected was submitted to statistical analysis using the statistical package SAS - -Statistical Analysis System, version 6.04. In order to compare age between the two groups, we used t Student test. To assess the association between result of culture and the other categorical variables we employed Fischer exact test. The level of significance was 5%.

Figure 1. CT coronal section of paranasal sinuses showing pansinusitis and calcification areas in patients with FS by Aspergillus sp.



Figure 2. Polyps and allergic mucin occupying the right middle meatus of a patient with FS by Candida tropicalis.



Figure 3. Electron photomicrography of genus Candida.



Figure 4. Culture of Cladophialophora carrionii in solid Sabouraud.

RESULTS

The 20 examined patients were aged 42 years on average (ranging from 10 to 69 years), 13 (65%) were female and 7 (35%) were male subjects.

The most frequently associated comorbidity was systemic hypertension found in six patients. No patient presented orbital or intracranial complication. Two patients (10%) had already been submitted to previous sinusal surgeries for the removal of nasal polyps.

Complementary Tests - In the computed tomography (CT scan) 100% of the patients presented signs of chronic sinusitis in more than one paranasal sinuses. In none of them the sinusal material had suffered overflow into the perisinusal regions, such as the orbit and brain (Figure 1).

As to serum dosages of total IgE, eight patients (44.4%) presented high serum levels, whereas in 10 (55.6%) they were within normal range (Graph 1).

Out of the 13 patients in which Af-specific IgE was tested, in only one case (7.7%) it was found in increased levels, whereas in the others (92.3%) the levels were normal.

Eosinophilia was found in 10 patients (50%) and in the remaining patients the levels were normal. Counts greater than 10% were found in 3 cases (15%).

PT using the aeroallergens already mentioned were positive for two or more antigens in 13 cases (68.42%) and negative in 6 cases (31.58%).

PT and Af were considered positive in 3 cases (15.8%) and negative in 16 (84.2%).

We observed fungal growth on sinusal material in 6 patients (30%), whereas 14 cultures (70%) were negative.

The most prevalent fungus was Aspergillus sp, found in four cases, followed by Candida tropicalis and Cladophialophora carrionii (C. carrionii) in one patient each (Graph 2). The description of sinusal culture with macroscopic aspect of allergic mucin was reported in 4 patients (20%). Three of them had positive culture.

The histopathologic analysis revealed the presence of fungal hyphae in only one patient whose culture grew C. carrionii. Eosinophils were identified in all slides, in smaller or larger amounts.
Comparison between studied variables

Age - Positive Culture x Negative Culture - The mean age (32.83) of patients with positive culture was lower than that of the other group (45.92%). The difference was not statistically significant (p= 0.15).

Sex - Positive Culture X Negative Culture - Among the 14 patients with negative culture, 10 (71.43%) were female and four (28.57%) were male subjects. Among the patients with positive culture, three (50%) were male and three (50%) were female patients. There was statistically significant difference (p= 0.33) between these items.

Bronchial Asthma - Out of the total of 20 analyzed patients, three (15%) had asthma. Among them, only one had positive culture.

Intolerance to NSAID- Out of 20 studied patients, 2 (10%) reported intolerance to NSAID. One belonged to the group of patients with positive culture and the other to the negative culture group.

Previous nasosinusal surgeries - The only 2 patients (10%) who had been submitted to previous surgery presented positive culture. No patient with negative culture had been previously submitted to nasal or sinusal surgeries.

Total IgE - Positive culture x Negative culture - Out of the patients with positive culture, two (40%) had high serum levels of total IgE, whereas 3 (60%) presented normal values. The analysis was not conducted in one patient.

Among the patients with negative culture, six (46.15%) presented increased values and seven (53.85%) had normal values. This association was considered not statistically significant (p=0.61) (Graph 3).

Af specific IgE - Since this test was conducted in only 13 patients, we did not have sufficient figures for comparison. In the group with positive culture, it was conducted in 4 subjects and in only one it was positive.

Eosinophils - Positive culture x Negative culture - Among the patients with negative culture, six (42.86%) presented normal counts of serum eosinophils and 8 (57.14%) had high levels. Among the patients with positive culture, these values were, respectively, four (66.67%) and two (33.33%). The association did not produce statistically significant difference (p= 0.31) (Graph 4).

PT with Af antigen - Positive culture x Negative culture - Among the patients with positive culture, PT was conducted in 5 cases, and considered negative in 4 of them (80%) and positive in only one (20%). Among the patients with negative culture, PT was negative in 12 (85.71%) and positive in two cases (14.29%).

As to other aeroallergens, PT resulted in positive response, with one or more antigens in 3 patients (60%) who had positive culture and in 10 (71.4%) who had negative culture.

Macroscopic aspect of sinusal secretion - Among the six patients with positive culture, in three we had description of involvement of the paranasal sinuses by large amounts of thick and mucous secretion. Among the patients with negative culture, this aspect was reported in only one case.

Graph 1. Serum levels of total IgE in patients with NP.



Graph 2. Results of sinusal secretion cultures.



Graph 3. Serum total IgE - Positive culture X Negative culture.



Graph 4. Peripheral blood eosinophil count - Positive culture X Negative culture.

DISCUSSION

NP is a relatively common disease in our hospital. The observation of its behavior in clinical practice concerns us because, regardless of the clinical and surgical treatment employed, some patients remain asymptomatic during years, whereas other present recurrence months after the surgery. Most of the patients are treated together by the ambulatory of Otorhinolaryngology and Clinical Immunology at HUCFF.

The interest by the topic was raised when a 9-year-old child presented repetitive pansinusitis, non-responsive to various antibiotic therapy regimens. At anterior rhinoscopy and nasal endoscopy we observed a great amount of thick secretion and polyps that occupied both middle meatus (figure 2). We ruled out the diagnosis of cystic fibrosis and the patient was submitted to nasosinusal surgery. All paranasal sinuses were filled with very thick and yellowish secretion. In the culture, there was growth of Candida tropicalis (Figure 3). Serum levels of Ig were normal, except for the IgG2 subclass, with values below normal. The symptoms reappeared right after the surgery, and we interrupted antibiotic therapy and started venous infusion of Igs. This case generated some questions. Was the fungus only opportunistic owing to the primary immunodeficiency? Was the NP a consequence of the presence of the fungus?

Most of the professionals are used to diagnosing FS in severely immunodepressed patients, in which the evidence of fungal invasion is well characterized. However, to investigate fungi in immunocompetent subjects with chronic rhinosinusitis and NP is a task that has attracted great interest in past years, especially after the recognition of the AFS 10.

The included patients did not have secondary immunodeficiency such as diabetes, AIDS, leukemia because in such cases, the fungus acts in an invasive way and is fulminating in many cases.

In the analysis of the results, some considerations were relevant for the comparisons with the literature data. Most of these comparisons were made with studies involving AFS and NP, since this type of FS is normally associated with NP.

The mean age of the 20 studied patients was 42 years, being below that (32.83) in subjects who presented positive culture. Four (20%) presented age below 16 years. Three of them had positive culture and one had it negative. Many authors13, 14, 15, 16 found mean age below that among patients with AFS.

NP is normally manifested in patients older than 20 years17. Manifestation in children is very rare, with reported incidences of 0.1%, cases in which we should suspect of cystic fibrosis13, 15. AFS is considered a disease that predominantly affect young adults, whereas others say it may affect indistinctly any age range14, 16.

Three adult patients (15%) presented bronchial asthma and 2 (10%) of them also had intolerance to NSAID, forming the "triad of Widal", also known as the "triad of Samter".

NP is presented in various systemic diseases and the most common association is with intrinsic or non-allergic asthma, more common in adults and rarely in children2, 16, 17. This type of asthma has its onset after the age of 30 years and NP appears at about the age of 40. In the case of the triad of Widal, asthma is usually severe and corticoid-dependent2. Approximately 20-50% of the patients with NP present bronchial asthma17.

Bent et al.5 confirmed that many patients with AFS present marked symptoms of asthma owing to chronic sinusitis.

Manning et al.18 analyzed 10 patients with AFS. The mean age was 32 years. Seven had history of allergic rhinitis and three, of asthma. All of them had NP and were immunocompetent.

Out of 3 patients in the study who presented asthma, only one had fungal growth (Af). It was a patient with recurrent NP, intolerance to NSAID and even after the second surgery, she maintained severe nasosinusal symptoms and difficult to control asthma, evidencing much thick and greenish secretion in both nasal fossae. Serum levels of total IgE were normal and PT for Af was negative. Other two patients with asthma and negative culture had good evolution and asthma drugs were reduced in the 3-month follow-up period.

The patient in whose culture we detected Candida tropicalis growth presented low serum levels for one IgG subclass, IgG2.

Immunoglobulins of class G present four subclasses: IgG1, IgG2, IgG3 and IgG4. The most common deficiency in children occurs in subclass IgG2 and in adults in IgG3. Owing to the constant exposure to infections that lead to edema of nasal mucosa and accumulation of sinusal secretion, it is common in such patients to find chronic and/or recurrent sinusitis, otitis media and pneumonia2, 18, 19.

NP is considered the most recurrent disease, and patients are submitted to various surgeries in order to attenuate the symptoms. It is also reported that patients with AFS are sometimes submitted to many surgeries before the definite diagnosis is made14, 20, 21.

Of the 20 analyzed patients, six (30%) presented fungal growth, being four of Aspergillus sp, one Candida tropicalis and another C. carrionii.

The predominance of a specific genus varies according to the type of sinusitis studied and the region in which the patients live. The fungi are widely distributed in the nature and dispersion of species enable equilibrium among themselves and the other organisms in their habitat22.

Aspergillus sp is the most frequent microorganism isolated in FS, especially in mycetoma 3, 23. They are saprobes of universal distribution, with filaments, and produce spores found in the atmosphere during all seasons of the year24.

In Brazil, fungi counts conducted in different cities show a great prevalence of genus Aspergillus over some others, especially the genus Penicillium and Cladosporium22,24. For a long time it has been admitted that conidia would have a medical importance, considering what has already been reported in other animal species, especially in the lung of birds24.

In patients with AFS the data are dispersed. Initially, there were cases of FS reported by Aspergillus, reason why they were known as allergic sinusitis by Aspergillus10. With time, the fungi from the family Dematiaceae started to be more frequently identified18,20.

Araujo et al.9 diagnosed 26 patients with FS. In the group, 11 had AFS: seven by Aspergillus sp, one by Candida sp, one by Fusarium sp and one by Alternaria sp. They found associated bacterial infection in 5 cases. Allergic mucin with hyphae was identified in 7 cases.

C.carrionii is a filamented fungus of the family Dematiaceae, whose old nomenclature used to be Cladosporium. These fungi are characterized by formation of a mycelium and/or dark color culture (Figure 4). They are considered high pathogenic to human beings and are responsible for some diseases, such as asthma and mycetoma 22.

We believe that the identified fungi participate in some way in the evolution of the NP, since they are not mere contaminants once 14 cultures were negative, data similar to those reported in the literature10, 20, 25, 26.

Many authors17, 25, 27, 28 suggested the association of the culture to the histopathologic analysis for the correct classification of type of FS. This exam can inform if there are fungi, if they invaded the mucosa or whether there are characteristic elements of allergic mucin.

In our study, the histopathologic analysis revealed presence of fungal hyphae in only one patient, in whose culture C. carrionii grew. Eosinophils were identified in all slides, in larger or smaller quantities.

In AFS and mycetoma many cultures are negative so it is up to the pathologist to identify the hyphae 14, 23, 29. The probable explanation for this fact is that many fungal elements are not viable, that is, there are no reproductive structures, which hinders growth23. As a result of improvement of culture techniques, the reports of positive results have increase. Many fungi that were previously considered contaminant are really pathogenic to humans16, 26.

Regardless of that, negative results are still very frequent. Many authors suggested that eosinophils present in large quantity in allergic mucin released the main basic proteins, considered toxic for the fungi. They become fragile and can deteriorate in vitro and do not survive in the cultures5, 16, 26. An allergic reaction in an atopic host regardless of the fungal load, which is sometimes minimal, can not be shown by the current techniques16.

There is even graver dilemma when the hyphae are found in the histopathologic exam with negative culture16.
In such cases some authors have used other identification resources, such as in situ hybridization for RNA of fungus and polymerase chain reaction9, 16.
The participation of allergy in NP and AFS is also a controversial topic. This was the reason why we decided to assess the reactivity of these patients with aeroallergens. A detailed investigation of the immune system includes a series of exams. To investigate the atopic state, in addition to personal and family history, we should conduct: eosinophil count in the peripheral blood and nasal secretion, cutaneous tests (PT) using various inhalation antigens, serum dosage of total and specific IgE.

Among those methods that had been more frequently used in patients with NP and AFS we can include eosinophil count in peripheral blood, cutaneous tests and serum doses of total and specific IgE for environmental antigens9, 14, 18, 19, 21, 30.

The exams that pointed towards the coexistence of an atopic state in these patients were eosinophil count (present in 50% of the cases) and PT for aeroallergens (positive in 68.42% of the patients).
Allergy as a determining factor for NP is a debatable topic. NP can be found in patients with rhinitis, asthma and negative cutaneous test. It is known that NP is not the manifestation of allergy, similarly to hives and rhinitis 2. In allergic patients, the concentrations of IgA, total and specific IgE, are much higher in the polyp tissue than in serum2.

Some authors referred to high positive values (56%) of the cutaneous tests in patients with NP. It can really happen if the sample is obtained in allergy clinics, in which the positive rate for prick tests reach 77%2.

Ponikau et al.28,29, 2000, differently from other authors, stated that there is not sufficient evidence in the literature that show the participation of hypersensitivity reaction mediated by IgE in the physiopathogenia of AFS. After the analysis of the patients with chronic rhinosinusitis, AFS can be present or not in cases of atopia. They also stated that mucosa lesions present in these patients are resultant from reactions mediated by eosinophil proteins and not by IgE.

Two patients who had positive culture were considered atopic and had AFS. These patients presented two or more abnormal exams, and the patient whose culture grew C. carrionii, presented high levels of total and Af-specific IgE, increased number of eosinophils in peripheral blood and positive PT for aeroallergens. The second patient whose culture grew Aspergillus sp, presented high levels of total IgE and positive PT for aeroallergens, including Af antigen.

Fungal growth can result from different situations that take to stasis of secretion of the paranasal sinuses and NP is one of them28, 29. The fungus can become antigenic in susceptible subjects, exacerbating the inflammatory process of the nasosinusal mucosa5, 25.

What is still not known is what triggers the proliferation and fungal growth in the sinus after the subject has been exposed to spores, making him develop one or another type of FS23.

CONCLUSIONS

Fungi genus Aspergillus continue to be the most frequently isolated type in paranasal sinuses cultures, but there is little that can be said about the real participation of these germs in the pathophysiology of diseases such as nasosinusal polyposis.

The results concerning clinical data were similar to those reported by the literature, including the frequency of asthma in patients with NP. The exception was with 4 patients (20%) who were aged below 16 years.

Serum levels of total IgE and eosinophil count in peripheral blood showed to be higher in a large proportion of the 20 patients of the study, as well as positive PT for aeroallergens, suggesting a coexistence in atopic states of these subjects.

A multidisciplinary team involving otorhinolaryngologists, immunologists, mycologists and pathologists is essential to allow drawing of such conclusions.

ACKNOWLEDGEMENT

To Roberto Jose de Lima - Assistant Professor, Department of Pathology, Medical School, UFRJ and to Maria Inez de Moura Sarquis - Researcher and Curator of Laboratório de Coleção de Cultura de Fungos IOC/ FioCruz.

REFERENCES

1. Triglia JM, Nicollas R. Nasal and sinus polyposis in children. Laryngoscope 1997;107:963-966.
2. Miyake MAM. Polipose nasossinusal: diagnóstico e tratamento. Rev Bras Otorrinolaringol 1998;64:11-21.
3. Allphin AL, Strauss M, Abdul-karim FW. Allergic fungal sinusitis: Problems in diagnosis and treatment. Laryngoscope 1991;101:815-820.
4. Araújo E, Stolz DP, Anselmi F. Sinusite fúngica. A Folha Médica 1998;117: 105-111.
5. Bent JP, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg 1994;111: 580-588.
6. Chhabra A, Handa KK, Chakrabarti A, Mann SBS, Panda N. Allergic fungal sinusitis: clinicopathological characteristics. Mycoses 1996;39: 437-441.
7. Cody DT, Neel HB, Ferreiro JA, Roberts GD. Allergic fungal sinusitis: The Mayo Clinic Experience. Laryngoscope 1994;104:1074-1079.
8. Goldstein MF, Dunsky EH, Dvorin DJ. Allergic fungal sinusitis: a review with four illustrated cases. Am J Rhinol 1994;8: 13-18.
9. Araújo E, Palombini BC, Stolz DP, Richter VT. Sinusite fúngica alérgica. A Folha Médica 1999;118: 5-11.
10. Katzenstein AA, Sale SR, Greenberger PA. Allergic Aspergillus sinusitis: a newly recognized form of sinusitis. J Allerg Clinical Immunol 1983;72: 89-93.
11. DeShazo RD, Swain RE. Diagnostic criteria for allergic fungal sinusitis. J Allerg Clinical Immunol 1995;96: 24-35.
12. DeShazo RD, Chapin K, Swain RE. Fungal sinusitis. New England J Med 1997;337:254-259.
13. Kupferberg SB, Bent JP. Allergic fungal sinusitis in the pediatric population. Arch Otolaryngol Head Neck Surg v;122:1381-1384.
14. Marple BF, Mabry RL. Comprehensive management of allergic fungal sinusitis. Am J Rhinol 1998;12:263-8.
15. Muntz HR. Allergic fungal sinusitis in children. Otolaryngol Clin North Am 1996;29:185-192.
16. Perez-Jaffe LA, Lanza DC, Loevner LA, Kennedy DW, Montone KT. In situ hybridization for Aspergillus and Penicillium in allergic fungal sinusitis: a rapid means of specifying fungal pathogens in tissues. Laryngoscope 1997;107: 233-240.
17. Kramer MF, Rasp G. Nasal polyposis: eosinophils and interleukin-5. Allergy 1999;54: 669-680.
18. Manning SC, Merkel M, Kriesel K, Vuitch F, Marple B. Computed Tomography and Magnetic Resonance Diagnosis of Allergic Fungal Sinusitis. Laryngoscope 1997;107:170-176.
19. Mabry RL, Manning S. Radioallergosorbent microscreen and total immunoglobulin E in allergic fungal sinusitis. Otolaryngol Head Neck Surg 1995;113: 721-723.
20. Corey JP, Delsupehe KG, Ferguson BJ. Allergic fungal sinusitis: Allergic, infectious, or both? Otolaryngol Head Neck Surg 1995;113: 110-119.
21. Schubert MS, Goetz DW. Evaluation and treatment of allergic fungal sinusitis. I. Demographics and diagnosis. J Allerg Clin Immunol 1998;102: 387-394.
22. Sarquis MIM, Oliveira PC. Diversity of microfungi in the sandy soil of Ipanema Beach Rio de Janeiro, Brazil. J Basic Microbiol 1996;36:51-58.
23. DeShazo RD, O'Brien M, Chapin K, Soto-Aguilar M, Swain R, Lyons M, Bryars WC, Alsip S. Criteria for the diagnosis of sinus mycetoma. J Allerg Clinical Immunol 1997;99:475-85.
24. Abe AT, França AT, Valle SOR. In: França AT. Aspergilose Broncopulmonar Alérgica. 1ª edição, Rio de Janeiro: Studio alfa; 1996. p. 21-35.
25. Kinsella JB, Bradfield JJ, Gourley WK, Calhoum KH. Allergic fungal sinusitis. Clin Otolaryngol Allied Sciences 1996;21: 389-392.
26. Ponikau JU, Sherris DA, Kern EB, Homburger HA, Frigas E, Gaffey TA, Roberts GD. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999;74:877-884.
27. Pereira EA, Stolz DP, Palombini BC, Severo LC. Atualização em sinusite fúngica: relato de 15 casos. Rev Bras Otorrinolaringol 1997;63:48-54.
28. Ponikau JU, Kern EB, Sherris DA. Allergic fungal sinusitis (letters). Mayo Clin Proc 2000;75:122-123.
29. Ponikau JU, Sherris DA, Kern EB. Role of fungi in allergic fungal sinusitis and chronic rhinosinusitis. Mayo Clin Proc 2000;75: 540-541.
30. Manning SC, Mabry RL, Schaefer SD, Close LG. Evidence of IgE-mediated hypersensitivity in allergic fungal sinusitis. Laryngoscope 1993;103: 717-721.

---

1 Master in Otorhinolaryngology, Medical School, Federal University of Rio de Janeiro (UFRJ).
2 Faculty Professor, Discipline of Clinical Immunology, UFRJ.
3 Faculty Professor, Department of General Microbiology, Head of the Laboratory of Chemical Biology of Microorganisms, Institute of Microbiology, UFRJ.
4 Ph.D. in Biological Sciences, Institute of Microbiology, UFRJ.
5 Professor, Course of Specialization in Clinical Immunology, Master in Immunology, UFRJ.
6 Otorhinolaryngologist, Post-graduate studies under course, UFRJ.

Study conducted at the Services of Otorhinolaryngology and Clinical Immunology, University Hospital Clementino Fraga Filho (HUCFF), UFRJ, part of the master dissertation thesis in Otorhinolaryngology submitted on April 25, 2001.
Address correspondence to: Carla Ribeiro Monteiro - Rua Nilo Peçanha n° 1/1309 Bl. 4 Ingá Niterói -RJ 24210-480 - E-mail: carlaandreiuolo@zipmail.com.br

Article submitted on March 14, 2002. Article accepted on July 18, 2002

Print: