Chronic Invasive Fungal Sinusitis Treatment

[Dr. Ashley Agan]
For patients, let's say you have made the diagnosis, you got tissue confirmation, you have fungus that is invasive within the tissue and you say, okay, this is a chronic invasive fungal sinusitis. What do the next several months look like for that patient, as far as like how long do they need to be on antifungals and what's their surveillance like with you?

[Dr. Gopi Shah]
Also, do you have to go and do like a FESS? Is there any role of opening things up for irrigations or topicals or anything like that after the biopsy?

[Dr. Ashleigh Halderman]
Yes. I think I'll start with that, Gopi, because that's an important discussion point with chronic granulomatous and chronic invasive is how aggressive surgically do you get. I think that we're at this interesting time where in the past, people used to advocate for very aggressive surgical resection of all involved tissue. I've never done that and I don't think that really maybe needs to play a part anymore in the management of these patients. I think that way of thinking and that management was born out of necessity back when amphotericin was non-liposomal and it would cause kidney failure. It was just people couldn't be on it for more than a few days at a time because their organs would start failing. It was a really self-limited option.

Now that we have the liposomal amphotericin and it no longer causes immediate organ failure or in a really rapid time period, we've got a lot more time. I'd say that even more importantly, the azole and the development of those has led to improved medical management of these patients, which has reduced the necessity of being surgically aggressive. In these cases, because of where they tend to go, so orbital apex, orbit, sphenoid, surgical resection, pterygopalatine fossa. Surgical resection would be quite morbid and potentially fatal. You're really in a tough spot there.

We definitely take a more measured surgical approach. I don't think it ever hurts to open things up if this isn't concurrent with like fungal ball or allergic fungal sinusitis. I'm going to open those sinuses up to remove all of the fungal debris that's sitting there on the surface. If there's anything by chance that is necrotic or you're concerned about viability, you could always debride that as well. Mostly you're going in there just to get a diagnosis in my opinion. Some people might disagree and I think some people still go after that really aggressively, but that's just not something that we do here.

Then it's all about getting the specimen the speciation, knowing what it is and putting them on appropriate antifungals. Then the surveillance is imaging based. You're looking to see if this stuff clears up. In my experience, people have been on antifungals typically until maybe a little bit after the imaging sort of resolves. If the imaging never resolves, so long as they're not getting worse, that makes you think that maybe there's something else going on that you need to go back in there. Maybe it's a different fungus that's not being sort of controlled by their current oral antifungal medication. Sometimes like that person I started off talking about, that woman who had intracranial, they're going to be on it for the rest of their lives.

[Dr. Gopi Shah]
For that patient, do they just have like a PICC line or a port and they're doing IV infusion every day?

[Dr. Ashleigh Halderman]
No, that's the beautiful thing about the azoles, is that they're all oral. Voriconazole, itraconazole, propiconazole, all oral.

[Dr. Gopi Shah]
Got you. They're on amphotericin until it speciates and then you can convert to oral.

[Dr. Ashleigh Halderman]
Exactly. Yes. It's just like broad spectrum antibiotics until you can narrow it down.

[Dr. Gopi Shah]
What does that timeframe look like?

[Dr. Ashleigh Halderman]
Months and months and months.

[Dr. Gopi Shah]
How long do you think it usually takes to get that speciation and get them transitioned?

[Dr. Ashleigh Halderman]
Oh, that could take about a week or so. What I've been finding is that a lot of times they will transition them off the ampho quickly. They might be on that for like three to five days or something. Maybe even before they have the speciation with maybe some of the earlier information they can start to put them on. I think posiconazole has been a popular option. They might go ahead and do that. It probably depends on the infectious disease doctor and sort of what's going on with the patient overall as far as like renal function, all that.

[Dr. Ashley Agan]
Just going back to the initial presentation, it sounds like this is usually a unilateral presentation?

[Dr. Ashleigh Halderman]
I have not seen it bilateral, fortunately. I am not aware of any reports of it being bilateral.

[Dr. Gopi Shah]
After they're discharged, when do them back? When do you order that first surveillance imaging?

[Dr. Ashleigh Halderman]
I'll usually see them at about a week just to check in. Mostly that's sort of like a, hey, let's make sure that you've got your other follow-ups and that you're on your medications, and that you understand that you're going to need to be on these. Then typically the repeat imaging is up to ID, and I let them decide that. I probably wouldn't get it earlier than one month and would maybe go about 3 months, 6 to 12 weeks of treatment before doing that, and then go from there. It's a conversation with you and ID.

[Dr. Gopi Shah]
That's an MRI usually?

[Dr. Ashleigh Halderman]
Typically, yes.

[Dr. Ashley Agan]
Are sort of the three main things as opposed to any of the sino-nasal symptoms that they probably didn't have to begin with for this.

[Dr. Ashleigh Halderman]
Correct. Right. It's like the absence of sort of sino-nasal symptoms. I think in a few series of patients, like everybody presented with headache or facial pain.

[Dr. Gopi Shah]
Do those symptoms respond pretty quickly?

[Dr. Ashleigh Halderman]
They do actually. Yes. The woman that I had mentioned who had the severe facial pain for a year prior to presentation, her pain rapidly got better, which was very rewarding and she was grateful.

[Dr. Gopi Shah]
Awesome. This has been a really informative, really great talk. As we round things out, anything that we've missed or anything we need to make sure that we touch on before we let you go?

[Dr. Ashleigh Halderman]
No. I think it's worth just sort of repeating the fact that the question of how aggressive surgically do you need to be is very up in the air right now. I can speak from experience when I say I've not regretted not being more surgically aggressive. I would say that in the majority of patients that I have treated, we've done limited debridement just to get the diagnosis and then really relied on the better antifungals that we have now and in a very prolonged course of treatment. We've not disfigured anybody unnecessarily or blinded them or removed an eye or anything like that and they've survived.

I would say if you're faced with one of these cases, don't swing for the fences necessarily. I think that that's something that we as a field need to really revisit, is the necessity of aggressive surgical treatment in these patients with the new age of antifungals.