Concurrent diagnosis of sinus fungus ball and invasive fungal sinusitis: A retrospective case series

Background Sinus fungal ball (SFB) is the most common type of non-invasive fungal sinusitis and develops mostly in immunocompetent individuals, whereas invasive fungal sinusitis (IFS), with high mortality, develops mostly in immunocompromised patients. SFB may progress to IFS depending on the patient's immune status and underlying diseases. Objectives To investigate the possibility of SFB progressing to IFS. Patients/methods A total of 10 patients histopathologically diagnosed with concurrent IFS and SFB from January 2013 to December 2019 were enrolled. Their clinical characteristics, histopathology, and clinical course information were obtained and compared with those of 56 patients with IFS alone and 617 patients with SFB alone. Results Acute, chronic, and chronic granulomatous IFS was diagnosed in two (20%), five (50%), and three (30%) patients, respectively. All patients had severe facial pain and/or headache, with the most common comorbidity being diabetes (n=5, 50%). SFB was identified in the maxillary (60%) and sphenoid (40%) sinuses. The tissue culture was positive for Aspergillus species in five (50%) patients. Eight patients with chronic or chronic granulomatous IFS were successfully treated by debridement with voriconazole, and the two patients with acute IFS and severe neutropenia due to hematologic malignancy died. Compared to patients with IFS alone, patients with combined SFB and IFS were older, female dominant, and commonly had chronic or chronic granulomatous IFS. In addition, they were older and more commonly diabetic and immunocompromised than patients with SFB alone. Conclusions SFB may progress to IFS particularly in elderly and immunocompromised patients.