Sinusitis

Sinusitis is a common problem in people with HIV infection. In one retrospective review, 11% of hospitalised patients were affected by this disorder.¹⁸ Sinusitis is more common with immunodeficiency (CD4+ T cell count < 200/μL), and it is more likely to be extensive and chronic in very immunodeficient patients. Up to one-third of cases may be asymptomatic, although most have fever, headache and nasal discharge. A minority have facial pain and tenderness. Sinusitis should be considered in the differential diagnosis of headache and fever.

Most cases of sinusitis in people with HIV infection are caused by bacterial respiratory pathogens such as Streptococcus pneumoniae and Haemophilus influenzae, although Pseudomonas aeruginosa and Staphylococcus aureus may also be causative agents. Mycobacteria spp., cytomegalovirus (CMV), Encephalitozoon spp., Cryptococcus spp., Aspergillus spp., Acanthamoeba spp. Cryptosporidia spp. and Pneumocystis jirovecii have all been reported as pathogens in people with HIV infection (Table 4).^19,20,21,22 Non-Hodgkin’s lymphoma also may affect the sinuses.²³

The presence of bony erosions on MRI or CT scan or ophthalmoplegia suggest possible infection with Aspergillus spp and mandates the need for biopsy.²⁴ Erosions may also be associated with Pseudomonas infection or lymphoma. Opportunistic pathogens need to be considered in the differential diagnosis, and a diagnostic aspirate should be performed in immunodeficient patients and in patients who have a poor response to therapy or severe disease. Samples should be examined for bacteria, fungi, mycobacteria and microsporidia and other microbes depending upon the level of immunosuppression of the patient.

Standard therapy with antibacterial agents (e.g. amoxicillin with clavulanic acid), decongestant and expectorant agents is appropriate in most cases. In severe cases where parenteral therapy is required, a third-generation cephalosporin (e.g. ceftriaxone) is recommended. In non-responsive disease, broadening of the antimicrobial spectrum to cover Ps. aeruginosa and S. aureus should be considered, pending results of sinus sampling. Surgery should be considered in the presence of ocular complications, systemic disease not responding to empirical antimicrobial therapy, and in conjunction with antifungal agents in fungal sinusitis. Surgical intervention for infective sinusitis is as effective in people with HIV as in those without HIV.²⁵