Respiratory Medicine (1990) 84, 249-251 Allergic Aspergillus sinusitis: an Indian report A. SHAH,Z. U. KHAN*, M. SIRCAR,S. CHATURVEDI*,G. BAZAZMALIK~" AND H. S. RANDHAWA* Departmen ts cf Clinical Research, *Medical Mycology and t Pathology, Vallabhbhai Patel Chest Institute, University of Delhi, P.O. Box 2101, Delhi-110 007, India Introduction Until recently, the spectrum of Aspergillus related hypersensitivity respiratory disorders included three clinical forms viz., allergic bronchopulmonary asper- gillosis (ABPA), hypersensitivity pneumonitis and IgE mediated asthma. In 1983, Katzenstein et al. (1,2) demonstrated that ,4spergillus species could cause mucoid impaction in the paranasal sinuses akin to that of ABPA. They termed this newly recognised clinico- pathologic entity a.s 'allergic Aspergillus sinusitis' (AAS). The rarity of reports of AAS in the literature prompted us to describe this second case of AAS from India. Case Report In November 1988, a 26-year-old male business executive, a nonsmoker, was referred to the Clinical Research Centre of the Vallabhbhai Patel Chest Institute for evaluation of progressive nasal symptoms associated with breathlessness. His clinical course dur- ing the last 4 years was characterized by bouts of sneez- ing, watery nasal discharge and intermittent blocked nose. The patient often had purulent discharge from the nostrils and a postnasal drip. He volunteered a history of occasional passage of brownish plugs from the left nostril. A history of frontal headache, more on the left side, along with intermittent swelling of the left eye and facial pain was also obtained. Although wheezing was not present, he had experienced breath- lessness for the past 9 months which aggravated on exertion. These symptoms had steadily increased in severity and had begun to interfere with his routine activities. He had been treated occasionally with anti- biotics, nasal decongestants and antihistaminics with little or no relief of symptoms. The patient was a resi- dent of the metropolitan city of New Delhi and did not have a history of exposure to mouldy vegetable sub- strate. His mother had rhinitis associated with asthma Accepted withoutrevision15 February1990. while his elder sister had rhinitis but they were not available for investigations. Physical examination revealed a young man in no acute distress. Nasal mucosa was erytbematous and ulcerated with thick purulent secretions. The nasal septum was deviated to the right. A pale pinkish mass was visible in the left nostril. Posterior rhinoscopy revealed a polypoid mass. Sinus tenderness was present over both maxillary and frontal sinuses. Examination of the chest was not significant. A roentgenogram of the paranasal sinuses demon- strated haziness of the maxillary and frontal sinuses of both sides (Plate 1). Total white blood cell count was 8600, with 14% eosinophils. Pulmonary function tests were within normal limits. Precipitating antibodies against culture filtrate antigens of Aspergillusfi~migatus and A.flavus were detected. Intradermal challenge with antigens of A. fumigatus and A. flavus elicited strong type I and Ill hypersensitivity reactions. The total serum IgE level was found to be 7400 IU ml- ~ and A. filmigatus specific IgE level was 3.8 PRU ml- i. Chest radiograph did not detect any abnormality. Central bronchiectasis was not seen on hilar tomography. The patient was advised to undergo bilateral Caldwell Luc operation along with septoplasty. Necrotic material along with polyps were seen in both antrums. Histological examination of the biopsy material revealed an inspissated inflammatory exudate showing mucin, extensive coagulative necrosis (Plate 2), focal collection of eosinophils in various stages of disintegration with scattered fungal hyphae, and Charcot-Leyden crystals (Plate 3). Culture of the pathologic material from the maxillary sinuses yielded pure and heavy growth of A.fi~migatus. The diagnosis of AAS in this case was supported by (1) an atopic background, (2) peripheral blood eosino- philia, (3) type I and type Ili cutaneous hypersensi- tivity to A. fumigatus and A. flavus, (4) precipitating antibodies to A. fimTigatus and A.flavus, (5) elevated total and A.fi#nigatus specific IgE levels, (6) culture of A.fim~igatus from the maxillary sinuses, and (7) histo- pathologic observation similar to those of mucoid 0954-6111/90/030249+03 $03.00/0 9 1990 Bailli,~re Tindall