Adult Chronic Sinusitis and Its Complications

By G. Douglas Campbell Jr., MD, FCCP

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Medical Management in Special Situations

HIV

Among HIV-positive individuals, rhinosinusitis is common (estimates range from 7 to 60%), frequently severe, and often recurrent. Reasons postulated for this include obstruction of natural sinus ostia by nasopharyngeal benign lymphoid hyperplasia, lymphoma, or Kaposi's sarcoma, and decreased mucociliary clearance. In addition, immunologic defects in cell-mediated and macrophage function, an increase in the levels of IgE (purported to be the cause of the increased incidence of allergic symptoms among HIV-positive patients), and decreases in IgG levels may also play a role.⁴⁰ Despite the increased incidence of rhinosinusitis, only limited microbiologic studies have been reported. The cumulative findings to date suggest that among HIV-positive patients with early disease (CD4 count of > 200/mm³), the microbiology is similar to that in the non-HIV population and the treatment should be similar.⁴⁰ P aeruginosa has been recovered in HIV-positive patients, but only among those with a CD4 count of < 200/mm³. Cytomegalovirus and fungi have recently been reported as causes of rhinosinusitis. Increasing use of antibiotic prophylaxis may increase the risk of multiresistant virulent pathogens and fungal superinfections. In all HIV-positive patients with a CD4 count > 200/mm³ in whom conventional therapy has failed and in all patients with a CD4 count < 200/mm³, the physician should consider sinus lavage cultures for bacteria, fungi, and respiratory viruses (including cytomegalovirus); aggressive medical management, including prolonged antimicrobial therapy for P aeruginosa; and sinus surgery.⁴⁰

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