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Asthma

Should this be treated?

06/02/2008

Question:

I have had multiple sinus surgeries that resulted ultimately in creating one big sinus cavity in my face. I also had a transphenoidal hypophysectomy and later a removal of a fungal mass in that area. Following that surgery, I developed an osteomyelitis in the same area and began frequent bouts with severe bronchitisAcute bronchitis. The osteomyelitis was surgically removed but the breathing difficulties/bronchitis episodes continued.PFTs showed uncontrolled asthma (I have multiple allergies and intrinsic and extrinsic asthma).My sinus surgeon cultured my sinus infection recently and it grew Staph (not MRSA) and Scedosporium Apiospermum. I get treatment periodically with antibiotics for the sinusitis/bronchitis and medrol dose pack for the Staph but never was treated for the fungus. The sinus surgeon told my spouse and me that sensitivities to the fungus were not done as the fungus is not something that is treated. He also advised me to take steroids whenever I get these respiratory symptoms as whenever he scopes me things look very inflammed. I had testing done that did show my adrenal gland and pituitary are functioning. The episodes of infection sometimes involve ear infections and I now have scarring on my lung on CT scans from the bronchitis episodes. My pulmonologist told me I would probably have to remain on the several asthma meds that I have been placed on now. The antibiotics calm things down for a short time, then the colonization begins to grow more--with more prominent infections. I am tired of this. My PCP asks me what my sinus surgeon `plans to do about this` (I also have multiple drug allergies and she worries that antibiotics could make the fungus colonization worse). I tell her he told us nothing is done as far as the fungus. Should this be treated? Are there options. I do nasal saline irrigations and occassionally do Alkalol irrigations (but cannot do them as often as suggested due to ear pain). I couldn`t tolerate Muccomist (headaches/and I get migraines). The sinus surgeon tells me the thickened mucus that seats itself at the base of the back of the roof of my mouth, (when it becomes immobile), `recycles`. He explained thinner sinus drainage drips on the infected mass and on down into the upper airway, and that we could expect this pattern to remain chronic. I hate the thought of being confined to indoor air conditioning all summer with the breathing difficulties from the weather/smog/asthma. Thank you.

Answer:

Scedosporium Apiospermum is an invasive fungus that typically infects patients who are on medications that suppress their immune system such as lung transplantation patients. However there are reports in the medical literature of infection with this fungus in people with normal immune systems and in people who have been frequently on corticosteroid medication (prednisone). It is also known that this fungus can induce an allergic type reaction versus a frank infection, and to make things even more confusing one treats the allergic reaction with corticosteroids. So it is never a straightforward issue on whether to treat this fungus with specific anti-fungal medications or not. However, in a patient with poorly controlled asthma who has repeated bouts of this fungus growing on culture, depending upon the pulmonary function test results, the chest CT scan and the physical exam it may very well be advisable to specifically treat the fungal infection. An infectious disease specialist might be a good person to request be involved in your care to assist with this decision.

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Response by:

John G Mastronarde, MD John G Mastronarde, MD
Clinical Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University