Background: The current incidence of sinusitis and its impact on morbidity and mortality is still poorly investigated in allografted patients. Methods: We therefore conducted, during the last 3 years, a prospective survey in a cohort of 52 consecutive patients allografted in our institution (15 CML, 11 AML, 11 ALL, 8 NHL, 3 MDS, 1 AA, 1 CLL and 2 MM). Patients routinely underwent clinical and CT scan evaluation of the sinuses pre-BMT and nasal swabs or aspirations when indicated. The diagnosis of sinusitis was based on clinical symptoms and CT scan criteria such as hydro-aeric level or absence of sinus aeration. Results: At the initial screening, 14 patients (27 %) had sinusitis using these criteria. It is noteworthy that 80 % of them were poorly symptomatic and had normal CRP levels. Five of them underwent surgery and had a positive microbiological documentation (2 Staphyloccocus Epidermis, 1 bacteroides and 2 aspergillus Fumigatus). These 14 patients were treated with penicillin derivatives-based antibiotherapy or itraconazole. In this group, 8 patients developed overt sinusitis during BMT despite previous treatment: 4 resolved with broad-spectrum antibiotics therapy whereas four had to undergo secondary draining surgery. Thus, pre-BMT sinus screening had a positive impact in 6/14 cases who did not develop sinusitis during BMT. During all the study period (pre and post-BMT), 28 patients (52 %) suffered from sinusitis. During the post-BMT period, 15/52 (29 %) patients presented with symptomatic sinusitis, at a median onset time of day 6. Seven out of 28 (25 %) had no pre-BMT symptoms, the other eight being reactivation of pre-BMT sinusitis (50 %) despite treatment. Eleven of these 15 patients were treated using antimicrobial (piperacilline-tazobactam) and anti-fungal (amphotericin B) therapy. Fourteen eventually resolved, and one died from aspergillar sinusitis despite appropriate therapy and surgery. Late sinusites (post day 100) occurred in 17 patients, 33 % de novo and 67 % reactivated previous sinusitis. Thirteen had cGVHD treated with immunosuppressive drugs. In these patients, the pathogens were more frequently related to cellular immuno-deficiency: adenovirus (1), RSV (1), Candida (1), aspergillus (4) and EBV (1). Conclusions: We conclude that sinusitis is a significant factor of morbidity in BMT patients (reaching in incidence of 50 %). Biological parameters (CRP) and clinical manifestations (fever, pain) may be absent. Pre-BMT screening is of proven use, allowing to detect sinus involvement in 27 % of the patients and sparing 50 % of them from later reactivation, by appropriate medical or draining therapy. Since sinusitis can be lethal, this screening and prophylactic policy is useful, although not efficient in all these patients. The role of surgical interventions remains questionable in our small series. As far as the late sinusitis occurrence is concerned, routine imaging should be recommended in immuno-compromised patient suffering from cGVHD in which the cumulative incidence reaches 76 % and where symptoms may be masked by the use of steroids.
Full conference title:
43rd American Society of Hematology (ASH) Annual Meeting
- ASH 43rd (2001)