Column: Ask your doctor about AFS
Kim consulted me for "sinus" related issues about a year ago. At that time, she was 47, had moved to Arizona from Michigan about eight years ago and worked as a middle school teacher.
She has had nasal allergy (hay fever) symptoms since childhood. She received allergy desensitization injections for less than a year as a child and it was stopped because her family moved.
In the last two years, she got treated for sinus infections at least six times per year. She underwent sinus surgery for removal of polyps from her nose about eight years ago before moving to Arizona and one more time about three years ago in another town in Arizona.
Just recently before consulting me, her primary care physician treated her with two courses of antibiotics for a total of three weeks for a suspected sinus infection. She still felt stuffy and congested in the nostrils. On blowing the nose, she got dark green mucus of rubbery consistency (like peanut butter).
She could hardly breathe through the nose and could not smell or taste anything. She snored heavily and slept poorly. She felt tired and lacked energy as a result.
She had tried several over-the-counter and prescription allergy tablets without benefit. She could not tolerate aspirin and NSAIDs as they made her wheeze and cough.
Examination in the office revealed an exhausted patient with tired-looking eyes with dark circles around, congested and swollen tissues inside her nose, light greenish yellow mucus in her nostrils, bad breath and postnasal drainage of mucus.
Her right eardrum looked dull and red. Pressure over the sinuses elicited slight pain. Some wheezing could be heard intermittently on listening to her chest. The rest of the examination was normal.
Her blood tests revealed normal numbers of eosinophils (the type of white blood cell that typically goes up in number in allergy and asthma sufferers) and moderately increased IgE level (the antibody protein that causes allergy and asthma).
Her immune evaluation was completely normal without any indication of immunodeficiency (genetic or acquired defect of the immune system to fight infections). Allergy skin testing in the office showed that she was highly allergic to several grass, weed and tree pollens that are common in the Southwest.
She also tested moderately positive for three of the mold spores and cat and dog dander. Her breathing test in the office showed the presence of mild asthma. NIOX measurement of nitric oxide level in her exhaled breath showed significant elevation - indicative of allergic inflammation of airway lining.
A CT scan of the sinuses revealed complete opacification (whiteness instead of darkness) of all her sinus cavities in the skull - indicative of significant sinus infection.
I referred the patient to a local ENT doctor who recommended sinus surgery for the third time. Kim elected to undergo the surgery. Biopsy of tissues from her sinus cavities revealed the presence of a condition known as Allergic Fungal Sinusitis.
After the surgery, Kim was told to use saline nasal irrigations and intranasal steroid sprays (fluticasone) twice daily and to avoid aspirin and NSAIDs completely. She was also started on a prolonged and tapering course of steroids (prednisone) by mouth. She was referred back to me for starting allergy desensitization injections for pollens, mold and animal dander.
Now, it is a year since surgery and starting allergy injections, medications and saline irrigations of her nose, Kim has done exceptionally well with just one episode of sinus infection in the interim. She has been off prednisone for several months now. She receives her influenza vaccination every year and received a pneumonia vaccine once following my advice.
She washes her hands frequently. She takes her allergy and asthma medications regularly. She is able to breathe through the nose without any difficulty, can smell and taste food again (to her intense enjoyment!) and is able to work without getting tired. She is very thankful and pleased.
The above situation describes a classic case of someone with Allergic Fungal Sinusitis. It is common in Arizona, affecting people who are highly atopic (allergic, as shown by presence of positive allergy skin or blood tests) and who have a history of hypertrophic rhinosinusitis (nasal polyps and chronic sinus infections). Aspirin allergy and asthma may coexist.
Often they give a history of passing nasal casts (dark green mucus of peanut butter rubbery consistency) on blowing their noses. Typically, they have a normally functioning immune system.
It is not uncommon for such patients to undergo more than one sinus surgery before the condition is diagnosed and treated. The diagnosis is clinched by doing a biopsy and culture of sinus linings during sinus surgery. The biopsy shows presence of Allergic Mucin, eosinophils and other related material and fungal hyphae (fungal threads). The culture may grow fungus. Bipolaris and Aspergillus are the most commonly isolated fungi - perhaps due to their prevalence in Arizona.
Allergic Fungal Sinusitis is caused by allergic inflammation in the nose and sinus cavities caused by inhaling fungal spores. This is to be differentiated from common bacterial sinus infections and invasive fungal infections of the sinuses.
The later is a destructive process that erodes through bones of the skull and invades other organs by spreading through blood. The invasive fungal sinusitis is rare and typically affects people with compromised immune function and rarely affects normal healthy people.
If you get frequent and documented sinus infections requiring one or more sinus surgeries, talk to your doctor to find out if you have the Allergic Fungal Sinusitis.
Natarajan Asokan, M.D., F.A.A.P. is a board-certified allergist and immunologist. He can be reached at 1739 Beverly Ave, Suite 118, Kingman, AZ 86409 or (928) 681-5800 or www.trinityallergy.com.
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