Date: 26 November 2013
This patient with ABPA and chronic cavitary pulmonary aspergillosis has been stabilized on voriconazole treatment for >5 years. She had a degree of photosensitivity most of that time, noticed early in the course of voriconazole treatment. She is oxygen and wheelchair dependent and doesn’t go outside very much, so most of her light exposure has been indoor light. She developed rough scaly patches over her face, neck and lower arms. Dermatological review indicated multiple solar keratoses”. Skin biopsy from the right forearm confirmed this clinical diagnosis – “skin showing hyperkeratosis with a little parakeratosis and acanthosis. The keratinocytes have a glassy appearance but show nuclear atypia with dyskeratotic cells, and occasional suprabasal mitoses. The intraepidermal sweat ducts are spared. Appearances suggest an actinic keratosis with moderate to severe dysplasia.” These features are characteristic of a low grade premalignant change.
She was treated with local 5-fluorouracil cream (Efudix) (3 cycles) to the affected lesions. These photos were taken at the apogee of inflammation. The inflammation resolved after discontinuing the cream. This reaction is expected with application of this mild chemotherapy agent. Alternative or supplementary treatments include cryotherapy, curettage and cautery, if necessary. Following treatment her skin was much softer and considerably improved. Voriconazole has been stopped, and posaconazole substituted.
Copyright:
DW Denning and JE Ferguson, University Hospital of South Manchester. 22/07/08
Notes: n/a
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Yamik catheter for rinsing nasal and paranasal cavities. Image C
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Yamik catheter for rinsing nasal and paranasal cavities. Image B
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Yamik catheter for rinsing nasal and paranasal cavities. Image E
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Patient with allergic fungal sinusitis. Eosinophilic mucin with A. flavus in the nasal cavity. Irregular crust of 2.5 cm from a patient diagnosed as allergic fungal sinusitis.
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This patient was diagnosed with Myelodyspasia/ Acute Myeloid Leukaemia in January 05. When he received intensive chemotherapy. Had previous history of chronic sinusitis, but after chemotherapy he developed significant maxillary sinusitis. He was treated with Caspofungin with good response, and subsequently with voriconazole. Patient has further CT scans in August 05 with myelodysplasia in remission.
A biopsy of ethmoid sinus in May showed a chronic inflammmatory process with bony invasion by fungal hyphae. The patient was in remission from myelodysplasia and was not undergoing treatment for this at the time of the scans.
In Aug 05 scans show the right maxillary sinus is now opacified. Destruction of superior medial wall of right maxillary sinus. Superiorly there was bone destruction with communication with the lower right ethmoid air cells. Lateral wall of right maxillary sinus remains thick walled with irregular periosteal thickening. No significant abnormality is seen within the nasal cavity or left paranasal sinuses. The biopsy of the ethmoid sinus revealed hyphae consistent with aspergillus. Since the patient was on voriconazole at this time this may indicate resistance. The case is ongoing with further surgery for debridement of right nasal side imminent. The patient is currently in remission.
Feb 06 D Denning
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This 33 year old woman with severe asthma since childhood and recent nasal obstruction, who did not fulfil the criteria for ABPA, had evidence of skin test sensitisation to Aspergillus. Itraconazole therapy orally improved her pulmonary symptoms and allowed a substantial reduction in the need for oral steroids and inhaled steroids. Nasal polyposis improved slightly, but she still required polypectomy and nasal steroids.
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