Chest
Volume 121, Issue 5, May 2002, Pages 1670-1676
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Opinions/Hypotheses
Sinobronchial Allergic Mycosis: The SAM Syndrome

https://doi.org/10.1378/chest.121.5.1670Get rights and content

We contend that the presence of concomitant allergic fungal sinusitis (AFS) and allergic bronchopulmonary mycosis in the same patient represents an expression of the same process of fungal hypersensitivity in the upper and lower airways. We have termed this process the SAM syndrome, an acronym for sinobronchial allergic mycosis. Diagnostic criteria have been established for the SAM syndrome, and the clinical characteristics of one previously unreported and four previously reported patients have been tabulated. Patients with the SAM syndrome have chronic sinusitis involving multiple sinuses, asthma, immediate cutaneous reactivity to fungal allergens, peripheral eosinophilia, and radiographic evidence of bronchiectasis. Total serum IgE levels are usually elevated as well. A variety of chest radiographic abnormalities may occur, ranging from mass lesions to diffuse pulmonary infiltrates and even normal findings on chest radiographs. Patients present for an evaluation of either sinus or lung disease and, at that time, demonstrate no clinical features that distinguish them from patients with isolated sinus or lung disease. All patients reported to date have had clinical responses to therapy with corticosteroids. We postulate that SAM is underdiagnosed in patients with AFS, a disease recently reported from medical centers in the southeastern and western United States. Moreover, since our patient had a mutation in the cystic fibrosis transmembrane conductor regulator (CFTR) gene, we further hypothesize that CFTR gene mutations may play an important role in the pathogenesis of the SAM syndrome.

Section snippets

Case Report

A 17-year-old, African-American, male, high school athlete with mild intermittent asthma presented to the University of Mississippi Medical Center for the evaluation of chronic sinusitis. A physical examination demonstrated an edematous nasal mucosa, nasal polyps, and thick mucus. Bilateral wheezes were present on auscultation of the chest. Despite long-term antibiotic therapy and therapy with topical nasal steroids, his symptoms of nasal obstruction and intermittent purulent discharge

Materials and Methods

Computer-based literature searches were used to identify all case reports of concomitant AFS and ABPM in the medical literature published in English (MEDLINE; National Library of Medicine; Bethesda, MD). These case reports were carefully reviewed, and the findings were compared to those for our patient.

Stringent diagnostic criteria for ABPM and AFS were used for inclusion of case reports in this study. Diagnostic criteria for AFS, as previously published by us,4 include the following: (1)

Results

Eight case reports of patients with concomitant AFS and ABPM were identified in the literature.17,18,19,20,21,22,23 Four of the cases did not meet our diagnostic criteria for AFS and ABPM.21,22,23 A 48-year-old woman reported by Travis et al21 did not meet the criteria for ABPM, although testing of a biopsy specimen from a right upper lobe lung nodule did reveal allergic mucin. The patient had no history of asthma or CF, did not demonstrate the presence of fungal-specific IgE by skin test or

Discussion

The five convincing case reports of patients with concomitant AFS and ABPM reviewed here clearly demonstrate that these diseases occur together and constitute a syndrome of sinobronchial allergic mycosis (SAM). A classification of sinopulmonary syndromes is presented in Table 2. Patients with SAM are atopic individuals who have asthma, rhinosinusitis, and high levels of total and fungal-specific IgE. The common histopathologic findings of eosinophilic mucin with layers of cellular debris and

ACKNOWLEDGMENT

The authors thank Drs. Steven Bigler and John Conforti for their helpful review of the histopathologic and radiographic features of this patient, and Doris Miller, Karen Davis, and Dawn Chism for assisting with the preparation of the manuscript.

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