HSC Section 8_April 2017

FUNGAL MOE: PITFALLS, DIAGNOSIS, AND TREATMENT

the gallium scan to return to normal, but because there can be a lag period between resolution of disease and a nor- mal scan result, we may be overtreating in these cases. A drop in the ESR can be used as a monitor for response to treatment, whereas a negative result in the gallium scan is an indicator to stop treatment altogether. All 3 patients we report here had already been treated in the community. Patient 3 was particularly interesting, as she was actually referred as a case of glomus jugular tu- mor. She was found, instead, to have 2 organisms on tissue culture, with Aspergillus being one of them. Her disease even progressed to involve the contralateral temporal bone through the clivus. All 3 patients had previously neg- ative swab cultures. They all had findings confined to the middle ear but were complaining of ear pain/trismus/ headache out of proportion to their clinical findings. Various protocols of empiric treatment, which would cover the most likely organisms in culture-negative MOE, have been proposed. Djalilian et al. (15) recommended in- travenous administration of ceftazidime or aztreonam for penicillin-allergic patients along with high-dose oral cip- rofloxacin and topical aminoglycoside steroid drops. None of these empiric protocols include amphotericin. Owing to its toxic nature, empiric amphotericin treatment for culture-negative MOE is not justified. With the intro- duction of voriconazole, which has few adverse effects, one might consider adding it as an empiric treatment for culture-negative MOE. The otolaryngologist must have a high index of suspi- cion for any patient with a background of immunosup- pression (diabetes or otherwise) with ear pain out of proportion to the clinical findings, which can sometimes be subtle or confined to the middle ear. It is specific in such cases that fungal MOE should be considered, with tissues and/or middle ear aspirates sent for fungal culture and appropriate treatment started. This can spare the patients grief, frustration, and, sometimes, unnecessary surgery. Voriconazole has been very effective in treating Aspergillus MOE on an outpatient basis. Like quinolones in Pseudomonas infection, it dramatically changes the treatment of Aspergillus MOE from inpatient to outpa- tient with much fewer adverse effects and less toxicity. CONCLUSION

Acknowledgments: The authors thank Aiman Ali, B.Sc. Radiology Sciences, in his help with the computed tomographic scans included in this article.

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