Allergic fungal rhinosinusitis - 04/08/18

Doi : 10.1016/j.jaci.2018.06.023

Mark S. Dykewicz, MD ^a,^⁎ , Jonathan M. Rodrigues, MD ^b, Raymond G. Slavin, MD, MS ^a
^a Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Mo
^b Allergy and Immunology, Sanford Health, and the Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Bismarck, ND

^∗Corresponding author: Mark S. Dykewicz, MD, Saint Louis University Allergy and Immunology, 1402 S Grand Blvd, M157, St Louis, MO 63104.Saint Louis University Allergy and Immunology1402 S Grand Blvd, M157St LouisMO63104

Abstract

Information for Category 1 CME Credit

Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions.

Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI Web site: www.jacionline.org. The accompanying tests may only be submitted online at www.jacionline.org. Fax or other copies will not be accepted.

Date of Original Release: August 2018. Credit may be obtained for these courses until July 31, 2019.

Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease.

Target Audience: Physicians and researchers within the field of allergic disease.

Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

List of Design Committee Members: Mark S. Dykewicz, MD, Jonathan M. Rodrigues, MD, and Raymond G. Slavin, MD, MS (authors); Zuhair K. Ballas, MD (editor)

Disclosure of Significant Relationships with Relevant Commercial

Companies/Organizations: The authors declare that they have no relevant conflicts of interest. Z. K. Ballas (editor) disclosed no relevant financial relationships.

Activity Objectives:

1.	To distinguish allergic fungal rhinosinusitis (AFRS) from other fungal sinus diseases and from chronic rhinosinusitis with nasal polyposis (CRSwNP).
2.	To understand the pathogenesis of AFRS.
3.	To recognize the evidence supporting different treatment modalities in patients with AFRS.

Recognition of Commercial Support: This CME activity has not received external commercial support.

List of CME Exam Authors: Vivian Aranez, MD, Matthew Mavissakalian, DO, Kiley Bax, MD, Christopher Gordon, DO, Weyman Lam, MD, Heather Lehman, MD, Sean Brady, MD, and Aasha Harish MD

Disclosure of Significant Relationships with Relevant Commercial

Companies/Organizations: The exam authors disclosed no relevant financial relationships.

Allergic fungal rhinosinusitis (AFRS) is a subset of chronic rhinosinusitis with nasal polyps (CRSwNP) characterized by antifungal IgE sensitivity, eosinophil-rich mucus (ie, allergic mucin), and characteristic computed tomographic and magnetic resonance imaging findings in paranasal sinuses. AFRS develops in immunocompetent patients, with occurrence influenced by climate, geography, and several identified host factors. Molecular pathways and immune responses driving AFRS are still being delineated, but prominent adaptive and more recently recognized innate type 2 immune responses are important, many similar to those established in patients with other forms of CRSwNP. It is unclear whether AFRS represents merely a more extreme expression of pathways important in patients with CRSwNP or whether there are other disordered immune responses that would define a distinct endotype or endotypes. Although AFRS and allergic bronchopulmonary aspergillosis share some analogous immune mechanisms, the 2 conditions do not occur commonly in the same patient. Treatment of AFRS almost always requires surgical debridement of the involved sinuses. Oral corticosteroids decrease recurrence after surgery, but other adjunctive pharmacologic agents, including topical and oral antifungal agents, do not have a firm evidence basis for use. There is good rationale for use of biologic agents that target eosinophilic inflammation or other type 2 responses, but studies in patients with AFRS are required.

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Key words : Rhinosinusitis, fungal allergy, chronic rhinosinusitis with nasal polyps

Abbreviations used : ABPA, AFRS, AIT, CRS, CRSsNP, CRSwNP, CT, ILC2, MRI, NK, SCIT