To the Editor: I read with great interest the article by Ponikau et al, and I am writing to offer an alternative interpretation of their findings. The authors state that the unrefuted diagnostic criteria for AFS are (1) CRS; (2) presence of allergic mucin, ie, clusters of eosinophils and their by-products; and (3) the presence of fungal organisms within that mucin. In their study, they compared 210 patients with CRS and 14 controls. They found that the 2 groups differed on criteria 1 and 2, but not 3, the presence of fungus in their nasal mucus. Ninety-six percent of cases had positive fungal cultures from their noses, compared with 100% of controls. Cases averaged 2.7 organisms per person, compared with 2.3 in controls. Thirty-three percent of cases had an elevated total immunoglobulin E (IgE), compared with 29% of controls. There was no significant difference in specific IgE values between groups. The authors conclude that type I hypersensitivity is an unlikely mechanism for AFS because there was no difference in total or specific IgE between the groups. Given that the authors state that (1) histologic markers of CRS patients are the striking number of eosinophils in contrast to the near absence of eosinophils in controls and (2) many different fungi colonize everyone's nasal secretions, it would also seem reasonable to conclude that fungi play no role in the pathophysiology of this disorder. Nevertheless, the authors conclude that fungi are responsible for AFS. Perhaps this entity should be termed eosinophilic rhinosinusitis. This would provide for the possibility of 1 or more other etiologies (eg, pollen, dust mites) responsible for the presence of the eosinophilic mucin in these patients.
Fungal-diseases; Fungal-infections; Fungi; Immunoglobulins; Immunological-tests; Immunology; Biological-agents; Biological-factors; Biological-systems; Cellular-function; Cellular-reactions; Cellular-transport-mechanism; Cell-function; Cell-metabolism; Cell-differentiation; Cell-biology; Allergens; Allergic-disorders; Allergies