Aspirin-Exacerbated Respiratory Disease With Allergic Fungal Rhinosinusitis: A Case Series of Overlapping Sinonasal Endotypes

Abstract

Background

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a heterogeneous inflammatory disease with multiple underlying etiologies. Although several CRSwNP endotypes have been detailed, the current classification system does not adequately represent all patients with nasal polyps. We describe 2 patients meeting established diagnostic criteria for both aspirin-exacerbated respiratory disease (AERD) and allergic fungal rhinosinusitis (AFRS), which are considered distinct CRSwNP endotypes.

Objective

To describe patients meeting established diagnostic criteria for both AERD and AFRS in order to highlight deficits in the current CRSwNP endotype classification system as well as to expand awareness of the potential for aspirin desensitization as a treatment option in a subset of patients with AFRS.

Methods

Retrospective chart review with description of patient and diagnostic characteristics. AERD was diagnosed based on the presence of nasal polyps, asthma, and a documented history of sensitivity to nonsteroidal anti-inflammatory drugs. AFRS was diagnosed based on Bent and Kuhn criteria.

Results

Patients met established diagnostic criteria for both AERD and AFRS. Microscopic examination of sinus tissue revealed reactive bone, tissue eosinophilia (>10/high-powered field), and allergic mucin with noninvasive fungal elements. Subjects had an average of 4 endoscopic sinus surgeries and are currently maintained with adjunctive aspirin desensitization and/or anti-IL-5 biologic therapy.

Conclusions

This case series suggests that although they are treated as distinct CRSwNP endotypes, AERD and AFRS may have more overlap than was previously appreciated. Further research is needed to accurately identify discrete endotypes and associated treatment outcomes as we seek individualized patient care.