Surgical Experience in Treating Invasive Mycoses of the Upper Respiratory Tract in Hematological Patients and Patients Who Have Recovered from SARS-CoV-2 Infection

Introduction

In recent decades, there has been an increase in patients with invasive mycoses (IM) of the upper respiratory tract. This is associated with an increase in the number of patients with risk factors - immunodeficient states caused by prolonged use of glucocorticoids (GCS) and immunosuppressive drugs, oncological and hematological diseases, allogeneic hematopoietic stem cell transplantation (allo-HSCT), graft-versus-host disease (GVHD), HIV, prolonged massive antibacterial therapy, diabetes mellitus, bronchial asthma, and prolonged stay in the intensive care unit. Currently, the relevance of the occurrence of IM has increased due to the pandemic of the new coronavirus infection SARS-CoV-2, secondary immunodeficiency against the background of COVID-19 and its treatment.

Objective of the study

To study the characteristics of risk groups, the differences in endoscopic and radiological findings in lesions of the nasal cavity and paranasal sinuses caused by various pathogens of invasive mycosis. To assess the effectiveness and features of surgical treatment in immunocompromised patients with the sinus-orbital form of the disease.

Rodneva Yu.A., Baranova I.B., Popova M.O., Nikolaev I.Yu., Pinegina O.N., Dolgov O.I., Kondrashov M.A., Zaitseva A.N., Shvetsov A.N., Bykova T.A., Paina O.V., Goloshchapov O.V., Bondarenko S.N., Zubarovskaya L.S., Klimko N.N., Karpishchenko S.A., Yaremenko A.I., Ekushev K.A., Kulagin A.D.

Patients and Methods

The analysis included 9 cases of IM: at the R.M. Gorbatcheva Research Institute of Hematology and Transfusiology, 7 cases in hematological patients from 2018 to 2021, and 2 cases in the otorhinolaryngology department of the I.P. Pavlov First Saint Petersburg State Medical University in 2021 in patients who had undergone COVID-19.

Results

Patients with IM had underlying conditions: agranulocytosis due to antitumor chemotherapy for acute leukemias (n=4), allo-HSCT (n=2) with acute leukemia and Gurler's syndrome, and drug hapten agranulocytosis (n=1), as well as the use of corticosteroids for the treatment of COVID-19 (n=2). Gender: 3 men and 6 women. Age: from 1 year 8 months to 80 years, 3 children (33.3%) and 6 adults (66.7%). The main clinical manifestations of IM localized in the upper respiratory tract were: fever above 38°C – 77.8% (only in hematological patients), nasal breathing impairment – 100%, facial hyperemia and local swelling – 77.8%, pain/pressure and a feeling of fullness in the facial area – 77.8%, headache – 44.4%, ptosis – 22.2%, ophthalmoplegia – 11.1%. In two patients, IM of the upper respiratory tract was combined with lung involvement – 22.2%. The diagnosis of IM in 100% of patients included computed tomography (CT) of the paranasal sinuses, endoscopic examination, biopsy, direct microscopy, and cultural study of the biopsy. CT signs of IM: decreased pneumatization of the sinuses – 100%, destruction of bone tissue – 77.8%. During endoscopic examination: necrosis of the mucous membrane – 88.9%, destruction of bone structures – 77.8%. The diagnosis of IM was established using microscopy with calcofluor white staining of the biopsy (100%). Etiology of IM: mucormycosis (n=4), fusariosis (n=2), aspergillosis (n=2), combination of mucormycosis and aspergillosis (n=1). The pathogen culture was obtained from 6 patients: Lichtheimia corymbifera – 33.3% (n=2), Fusarium oxysporum – 16.7% (n=1), Fusarium solani – 16.7% (n=1), Aspergillus fumigatus – 16.7% (n=1), combination of Aspergillus niger, Aspergillus flavus, and Rhizopus arrhizus – 16.6% (n=1). Patients received systemic antifungal therapy according to international recommendations. Surgical treatment was performed in 100%, with patients having mucormycosis and fusariosis treated urgently, and patients with aspergillosis treated against the background of hematopoiesis recovery.

Conclusion

The main background conditions for the development of invasive mycosis localized in the upper respiratory tract are agranulocytosis and the use of glucocorticoids. A feature of invasive mycosis is the extremely rapid spread, leading to significant lesions in the form of necrosis, destruction, bleeding, and penetration into the orbit and cranial cavity. The success of diagnosis and therapy is possible only with a multidisciplinary approach to patient treatment. Early drug therapy and surgical tactics, which are determined by the specific pathogen, are key.

References

1. Invasive mycoses caused by rare pathogens in children with malignant tumors and non-malignant diseases of hematopoietic and lymphatic tissue against the background of bone marrow transplantation and antitumor chemotherapy. Rogacheva Y.A., Popova M.O., Markova I.V. et al. Pediatrics. Journal named after G.N. Speransky. 2019. Vol. 98.
   No. 1. P. 28-35.
2. Klimko N.N., Hostelidi S.N., Shadrivova O.V., et al. Invasive mucormycosis in oncological hematological patients (results of a prospective study). Oncohematology. 2017;12(2):14-22. https://doi.org/10.17650/1818-8346-2017-12-2-14-22