Sinusitis Complications in High Risk Children Can Be Challenging!
One of the most widely-read articles on this site is my post on the Complications of Sinusitis in Children. I wrote that nearly two years ago; it’s time for an update. Many parents worry about these complications. Every time their little boogor-head has nasal congestion, they wring their hands, worrying about the possibility of a brain abscess, or blindness. Keep in mind: these are extremely rare complications of sinusitis!
On the other hand, there is a population of children who are at increased risk: these are children who are high risk for complications of sinusitis. Parents of these children should be aware of the increased risk, and be especially vigilant when their little one becomes ill with sinusitis.
It should be obvious that a child who is immune-suppressed (from chemotherapy, or even a rare congenital gene mutation) may be at increased risk of complications from infections – any infection. In addition, there are a couple less-obvious, common diagnoses that can be associated with increased risk of complications from sinusitis.
This brief article reviews a couple of the “obvious” ones, and a couple of the “non-obvious.” And although my comments are focused complications of sinusitis in high risk children, most of my comments are applicable to adults who have these diagnoses as well. In some ways, all of the following diagnoses share the condition of “functional impaired immunity.”
Immune-suppression and Immune-compromise:
Any condition that results in reduction of absolute neutrophil count (ANC) below 500 cells /mm3 increases the risk of invasive fungal infection. Fungus and bacteria are always around us, everywhere. We don’t pay any attention because our neutrophils normally deal with fungus and bacteria in a number of very cool ways (at least, from the perspective of a cell biologist).
Our neutrophils provide “innate immunity,” stopping infections even before we have a chance to make antibodies against the would-be invader. However, children who have undergone bone marrow transplant, and children who are infected with HIV, can have low ANCs; this impairs innate immunity. If the ANC is low enough, bacteria and fungi can rapidly cause severe sinus infection. Acute fungal sinusitis can quickly become life-threatening in these children, even in this day of advanced surgical techniques and antibiotics.
Cystic Fibrosis (CF):
Despite the triumphant discovery in 1989 of the gene responsible for CF, children with CF continue to experience chronic, debilitating respiratory infections. This gene – the CFTR, or CF transmembrane conductance regulator – regulates NaCl transport across the cell membrane. But its effects go far beyond regulating the salt content across membranes. In fact, based on recent studies, we now understand that the CFTR mutation causes malfunction of several levels in their innate immunity. Thus, these children are also at increased risk of sinusitis complications.
Chronic hyperglycemia (elevated blood glucose) from diabetes can impair innate immunity. When measured, the ANC in these children may be well above the 500/mm3 level mentioned above, but if the neutrophils can’t do their job, the real, functional number may be below this danger level. Therefore: Diabetic children who experience poor diabetes control, resulting in chronic hyperglycemia, may have functional immune-compromise at multiple levels in the immune system, and thus be susceptible to the infections mentioned above. They can be at increased risk of sinusitis complications.
Unlike immune-compromise, CF, and diabetes, the problem caused by the sickle cell mutation is more of a mechanical, plumbing problem and less of a complex immune problem. Specifically, a single amino acid substitution in the hemoglobin molecule results in red blood cells becoming elongated, spiked, or “sickle” in shape.
These red blood cells are no longer compressible and pliable. These sickle cells cannot make it through the tiniest of capillaries – the microcirculation – like normal red blood cells. This can cause poor blood supply, and poor oxygen supply, to sites of infection.
When an infection is developing, good blood supply is important to bring those neutrophils to the site so they can kick some bacteria butt! If there’s a road-block of stacked-up sickle cells, neutrophils can’t do their job. Functional impaired immunity.
As infection continues, the reduced oxygen cause by reduced circulation causes a shift in the types of bacteria that thrive: there is a rapid trend toward anaerobic bacteria. Anaerobes generally pose a nasty infection. The reduced oxygen levels cause more sickling of the red blood cells, and things just get worse.
Bottom line: infections in children with sickle cell disease can rapidly escalate due to this expanding area of reduced oxygen, impaired circulation, and impaired immunity. They can be at high risk for sinusitis complications.
Primary Ciliary Dyskinesia (PCD):
I have written about immotile cilia / dysmotile cilia / ciliary dyskinesia here previously.
Mucociliary clearance is the primary innate immune function of the respiratory mucosa (the lining of the nose, sinuses, respiratory tract). So it stands to reason that children with PCD experience frequent infections of their respiratory tract.
These infections include ear infections (otitis media and mastoiditis), infections of their nasal lining (rhinitis), sinuses (sinusitis), and lower respiratory tract (including tracheitis, bronchitis, and pneumonitis).
These children experience severe, recurrent, and chronic infections as listed above; but aside from impairment of their mucociliary clearance mechanism, the remainder of their immune systems are intact. The result is that, unlike children with frank immune-compromise, diabetes, or sickle cell, infections in children with PCD are less likely to become life-threatening.
For all of these children described above, extra vigilance is necessary when they experience sinusitis. They may require unusually aggressive intervention, including hospitalization for IV antibiotics and possibly even very aggressive surgery, in addition to strong anti-inflammatories and regular saline nasal rinses.
Through the years, I have successfully treated children with all of these diagnoses. The sinusitis complications in high risk children that scared me the most – the ones for whom I came closest to failing – included children who had bone marrow transplants, teenagers with severe uncontrolled diabetes, and children with sickle cell disease. During their recovery, each and every one of them took years off my own life with worry.
Hi, I’m Russell Faust, author of this medical education blog. That wonderful photo of me is by Chris Stranad; here is his site: http://www.chrisstranadphotography.com/Index.html
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