What is the treatment for Aspergillus sinusitis?

Treatment of Aspergillus Sinusitis

The treatment for Aspergillus sinusitis requires a combination of surgical debridement and systemic antifungal therapy with voriconazole as the primary agent of choice, similar to the approach for invasive pulmonary aspergillosis. 1

Classification and Treatment Approach

Aspergillus sinusitis presents in several forms, each requiring specific management:

1. Invasive Aspergillus Sinusitis

• Primary therapy:

  • Voriconazole (6 mg/kg IV every 12h for 1 day, followed by 4 mg/kg IV every 12h; can switch to oral therapy at 200-300 mg every 12h) 1
  • Surgical debridement is essential as an adjunct to medical therapy 1

• Alternative therapy (for patients who cannot tolerate or are refractory to voriconazole):

  • Liposomal amphotericin B (3-5 mg/kg/day IV) 1
  • Isavuconazole (200 mg every 8h for 6 doses, then 200 mg daily) 1
  • Salvage options: ABLC (5 mg/kg/day IV), caspofungin (70 mg/day IV × 1, then 50 mg/day IV thereafter), micafungin (100-150 mg/day IV), or posaconazole 1

2. Allergic Fungal Rhinosinusitis

• Primary therapy:

  • Polypectomy and sinus washout 1
  • Topical nasal steroids, especially after surgery 1

• For refractory or rapidly relapsing disease:

  • Oral antifungal therapy with mold-active triazoles (e.g., itraconazole) 1

Evidence Supporting Voriconazole

Voriconazole has demonstrated superior efficacy in treating invasive aspergillosis compared to amphotericin B:

• 53% satisfactory global response with voriconazole vs. 32% with amphotericin B 2
• 71% survival rate at day 84 with voriconazole vs. 58% with amphotericin B 2
• Better tolerability profile than amphotericin B 3

Combination Therapy Considerations

In cases of extensive invasive Aspergillus sinusitis where surgical intervention is limited:

• Combination therapy with caspofungin and voriconazole may be considered for patients who cannot undergo surgery or tolerate amphotericin B 4
• This approach has shown rapid resolution in case reports of extensive infection 4

Duration of Therapy

• For invasive forms: Continue treatment until resolution or stabilization of all clinical and radiographic manifestations 1
• For chronic forms: Long-term therapy may be needed, potentially for months 1

Monitoring and Follow-up

1. Regular clinical assessment for treatment response
2. Therapeutic drug monitoring for voriconazole to ensure adequate serum levels
3. Monitor for adverse effects:
   • Visual disturbances (30% of patients on voriconazole) 3
   • Hepatotoxicity (monitor liver function tests) 5
   • Skin rashes (6% of patients) 3

Special Considerations

• Immunocompromised patients: More aggressive therapy is needed as mortality is particularly high in HIV-infected and other immunocompromised patients 6
• Posaconazole: Recent evidence shows non-inferiority to voriconazole for invasive aspergillosis with fewer treatment-related adverse events, making it a potential alternative first-line agent 5

Treatment Algorithm

1. Confirm diagnosis through imaging, histopathology, and/or culture
2. Assess invasiveness and extent of disease
3. For invasive disease:
   • Initiate voriconazole therapy
   • Arrange surgical debridement when feasible
4. For allergic fungal rhinosinusitis:
   • Perform polypectomy and sinus washout
   • Prescribe topical nasal steroids
   • Add antifungal therapy only for refractory cases
5. Monitor response and adjust therapy accordingly

Pitfalls to Avoid

• Delaying surgical intervention in invasive disease
• Inadequate duration of antifungal therapy
• Failure to monitor drug levels for voriconazole
• Overlooking drug interactions with voriconazole (particularly with anticonvulsants)
• Neglecting to assess immune status of the patient, which affects prognosis and treatment approach