|
 |
  |
 |
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
|
|||||||
- Allergic Fungal Sinusitis -
6/22/05 re: Treatment of allergic fungal sinusitis I have a patient with long-standing allergic fungal sinusitis (AFS) who needs to begin either Remicaide or Enbrel for moderate to severe seronegative arthritis.
1: I am unable to find any data on whether such patients are more likely to develop INVASIVE fungal infections (particularly of the sinuses) than are patients without AFS. I contacted the manufacturers, but they were of no help. Do you know whether such data exist?
2: A colleague suggested that the patient be placed on prophylactic voraconazole, but again was unable to provide me with any studies or data. Given the toxicity and drug interactions of the azole antifungals (as well as the theoretical possibility of developing resistant strains with long term antifungal therapy) do you believe this recommendation to be sound?
I know of no reports that allergic fungal sinusitis (AFS) becomes invasive during anti-TNF therapy. Therefore, I referred your questions to Dr. Raymond Slavin of St. Louis Univ., an expert in chronic sinusitis, including AFS. His response is enclosed below. As noted, he felt that it was very important to distinguish AFS from chronic hyperplastic eosinophilic rhinitis (CHERS) syndrome in which there is some fungal colonization (particularly when the patient has been receiving long-term antibiotic treatment).
If there is firm evidence for AFS (strong positive skin test to the suspect fungus, considerably elevated serum IgE), then he would recommend chronic steroid therapy tapering the dose as soon as feasible to that needed to keep in the AFS in check. Dr. Slavin commented that such a prednisone regimen would likely control much of the joint manifestations as well so that anti-TNF treatment may not be needed. A trial of local amphotericin, using thorough irrigation as described by Dr. Slavin, is worth while. A recent report described encouraging findings in a pilot trial of intranasal fluconazole along with systemic intraconazole and steroids in AFS. (see enclosed abstract). Neither he nor I would be enthusiastic about trying the systemic anti-fungal treatment you mentioned.
Dr. Slavin's comments
1. I, too, don't know of any evidence that AFS could evolve into an invasive form during anti-TNF therapy. It's an intersting question because of the known immunosuppressive effect of anti-TNF. AFS is marked by superficial invasion of the mucosa, although if there's enough involvement it can cause proptosis by its sheer bulk. I'd be inclined to hold back at least until a rheumatologist with a lot of experience with these drugs was consulted. (I just went down the hall to consult with ours, but he has left the building.) 2. Treatment of AFS is controversial largely because Ponikau insists on including AFS in his mix of cases with chronic hyperplastic eosinophilic rhinosinusitis (CHERS) Talk about a mixed bag! True AFS is best treated, I believe, by a long term course of prednisone as described by Mark Schubert (JACI 102:395,1998) Ponikau's treatment of CHERS with intranasal amphotericin looks promising. His JACI paper in 2002 involved 51 patients but was uncontrolled (110:862,2002). More recently, a small controlled study (JACI 115:125, 2005) by the Mayo group was provocative, but it only involved 14 patients treated with placebo, and 10 with ampho. It obviously calls for a large, multicenter study, and I understand one is in the works.The JACI paper you cite (113:1122, 2004) was terrible in that they only used a squeeze bottle of ampho whereas the Mayo group emphasizes real irrigation to reach the sinus cavity. So, in summary, if it's true AFS (positive skin test, elevated IgE, concretions in the sinuses on CT etc) I'd go for the long term prednisone route. If it's CHERS I'd try the intranasal ampho.
Ear Nose Throat J. 2004 Oct;83(10):692, 694-5. Related Articles, Links
Fluconazole nasal spray in the treatment of allergic fungal sinusitis: a pilot study.
Jen A, Kacker A, Huang C, Anand V.
Department of Otolaryngology, Head and Neck Surgery, New York Presbyterian Hospital of Columbia, USA .The authors describe a prospective pilot study designed to investigate the use of topical nasal antifungal spray in addition to systemic steroids and itraconazole in the treatment of allergic fungal sinusitis. Sixteen patients with a history of allergic fungal sinusitis were given fluconazole nasal spray and followed for 3 months. Stabilization or improvement of disease without significant side effects was observed in 12 of the 16 patients who were treated with this protocol. These results indicate that topical fluconazole application may help patients with allergic fungal sinusitis; however, a larger multicenter study with longer patient follow-up is required to validate these initial finding.
