Abstract
During the past three decades intranasal corticosteroid sprays have been proven to be efficient and reasonably safe for the treatment of rhinitis, sinusitis and nasal polyposis. The adverse effects are generally localized and self-limited and rarely systemic or significant. We report an immunocompetent female treated with triamcinolone acetonide nasal spray for chronic rhinitis in whom an intranasal fungal infection with Alternaria species developed three months later. The infection was refractory to topical therapies alone, and was resolved with a combination of systemic and topical antifungal therapy. We also described the clinical manifestations of this rare infection and our therapeutic experience. In addition, we reviewed previous literature of fungal infections related to nasal corticosteroid sprays and compared them with our report.
1
Introduction
Intranasal corticosteroid (INC) sprays are universally prescribed for treatment of allergic rhinitis , rhinosinusitis and nasal polyposis with excellent therapeutic effects. In general, the administration of INC sprays is reasonably safe, and significant or systemic adverse effects have rarely been reported. Some local adverse effects such as epistaxis, nasal irritation, sneezing, nasal dryness, burning sensation, cough, throat discomfort and pharyngitis have been reported in a few patients, however these complications were transient and self-limited . A rare but significant local complication of septum perforation was reported in one patient, although it was considered to be the consequence of mechanical trauma to the nasal septum . The potential adverse effect of intranasal candidiasis is included on the safety labels of marketable INC sprays approved by the United States Food and Drug Administration (USFDA), however few reports have demonstrated the clinical manifestations, appropriate treatment and therapeutic results of intranasal fungal infections. To the best of our knowledge, no previous reports have described an INC spray-related Alternaria infection. We first present a case with this rare adverse effect, and then describe the clinical presentation, local findings and therapeutic efficiency.
2
Case report
A 50-year-old woman presented with obstructive sleeping apnea (respiratory disturbance index: 29.0 per hour) and essential hypertension with no medical treatment. She was otherwise healthy, although she had suffered from perennial nasal obstruction and post-nasal dripping for years, for which she had never taken any medication or undergone sinonasal surgery. On examination, pale and hypertrophic turbinates, a deviated nasal septum and serous postnasal drips were observed with no nasal polyps, purulent drainage or other anatomical abnormalities. The serum total immunoglobulin E (IgE) level was 90.2 kU/L and no predominant allergens were detected by allergen-specific IgE tests. Triamcinolone acetonide nasal spray (Nasacort AQ, 55 mcq/ds, 120 ds/bot) with a dose of 110 mcq for each naris per day at bedtime was prescribed for treatment of the chronic rhinitis, and she used the INC spray regularly without overdosing or taking other medications. However, she complained of bilateral intermittent intranasal irritation and even pain lasting for a few days at an outpatient follow-up visit three months later. Detailed nasal endoscopy disclosed multiple white powdery patches on bilateral sides of the nasal septum and the caudal surfaces of the bilateral inferior and middle turbinates (see Fig. 1 ). The oral cavity, nasopharynx, oropharynx, hypopharynx and larynx were unremarkable without lesions or erythematous mucosa. Under the impression of an INC spray-related intranasal fungal infection, we discontinued the triamcinolone acetonide nasal spray. We then encouraged nasal douching with warm salted water and prescribed ketoconazole ointment (2%, 10 g/tube) to be applied to the infected turbinates and septum twice per day as topical therapy. A fungal infection with Alternaria species was subsequently confirmed by the results of cultures from swabs of the infected turbinates.
A workup to survey the underlying disease was initiated. The complete blood count was unremarkable with normal distribution of white blood cells and no immature cells. The fasting blood glucose level, creatinine level, liver enzymes, anti-nuclear antibodies, rheumatoid factor, and erythrocyte sedimentation rate were all within normal ranges. The quantitative immunoglobulin (Ig) blood test for IgG and IgA revealed antibody levels within normal range including the IgG subtypes. Chest radiography and abdominal echography did not reveal any significantly abnormal findings. In general, the patient was immunocompetent.
The turbinate lesions and nasal symptoms could be suppressed temporarily for days to weeks but easily relapsed, and consequently the congested infected turbinates resulted in intolerable nasal obstruction, irritation and pain. Therefore, we prescribed oral fluconazole (200 mg once per day) and enhanced the topical therapies with diluted fluconazole solution (50 mg fluconazole dissolved in 500 ml of warm salted water) for nasal douching followed by ketoconazole ointment applied to the infected turbinates and septum twice per day. After two weeks of treatment the nasal symptoms greatly improved, and the infection was eventually resolved with no further recurrence after one year of follow-up. The patient subsequently accepted submucosal resection of the deviated septum and hypertrophic turbinates to facilitate nasal breathing.
2
Case report
A 50-year-old woman presented with obstructive sleeping apnea (respiratory disturbance index: 29.0 per hour) and essential hypertension with no medical treatment. She was otherwise healthy, although she had suffered from perennial nasal obstruction and post-nasal dripping for years, for which she had never taken any medication or undergone sinonasal surgery. On examination, pale and hypertrophic turbinates, a deviated nasal septum and serous postnasal drips were observed with no nasal polyps, purulent drainage or other anatomical abnormalities. The serum total immunoglobulin E (IgE) level was 90.2 kU/L and no predominant allergens were detected by allergen-specific IgE tests. Triamcinolone acetonide nasal spray (Nasacort AQ, 55 mcq/ds, 120 ds/bot) with a dose of 110 mcq for each naris per day at bedtime was prescribed for treatment of the chronic rhinitis, and she used the INC spray regularly without overdosing or taking other medications. However, she complained of bilateral intermittent intranasal irritation and even pain lasting for a few days at an outpatient follow-up visit three months later. Detailed nasal endoscopy disclosed multiple white powdery patches on bilateral sides of the nasal septum and the caudal surfaces of the bilateral inferior and middle turbinates (see Fig. 1 ). The oral cavity, nasopharynx, oropharynx, hypopharynx and larynx were unremarkable without lesions or erythematous mucosa. Under the impression of an INC spray-related intranasal fungal infection, we discontinued the triamcinolone acetonide nasal spray. We then encouraged nasal douching with warm salted water and prescribed ketoconazole ointment (2%, 10 g/tube) to be applied to the infected turbinates and septum twice per day as topical therapy. A fungal infection with Alternaria species was subsequently confirmed by the results of cultures from swabs of the infected turbinates.
