Symptoms of a fungal ear disease

Dr. Hooman-Khorasani
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Fungal diseases and infections can be divided into two categories: superficial and invasive. Superficial infections are associated with colonization of the external auditory meatus and middle ear. Superficial non-invasive infections are manifested with minimal symptoms such as ear itching, discharge, unexpressed pain, this condition is often found in patients with impaired immunity after local or systemic antibacterial therapy with a decrease in the normal microflora of the middle ear and the skin of the external auditory meatus.    

The external auditory meatus and the tympanic membrane are most susceptible to the non-invasive fungal process , and the tympanic cavity may also be involved. Candida and Aspergillus are the most common pathogens of the fungal process. Otoscopy reveals pathological contents of black or white. Treatment includes ear toilet followed by topical antifungal medications such as drops of 1% clotrimazole or lotrimin / triamcinolone ointment.  

Invasive fungal infection usually occurs in immunocompromised patients. Cryptococcosis is usually manifested by neurological symptoms: headache, confusion, depression, and agitation during germination in the temporal bone in the terminal stage. 

Aspergillosis most often begins as a pulmonary infection with the direct entry of fungi through the auditory tube into the middle ear. Mucormycosis affects the paranasal sinuses and orbit and proceeds with lightning speed. All three types of fungus invasive infections of the external auditory canal, middle ear or mastoid process are quite rare in immunocompromised patients. 

The clinical picture includes severe acute pain with discharge from the ear, bleeding from the ear, sensorineural or conductive hearing loss. Dizziness and paresis of the facial nerve may be present. With invasive fungal otitis media, the most common pathogen are fungi of the genus Mucor, then Aspergillus and Cryptococcus. Treatment includes surgical treatment and the use of systemic antifungal drugs such as amphotericin-B. Invasive fungal infections are associated with severe complications and high mortality.  

Histopathologically, fungal infections can be identified by their characteristic appearance. Candida is dimorphic, that is, the fungus exists in two forms, unicellular and filamentous forms are more common, but candida can exist in the form of a pseudohyphus. 

Cryptococcus is a unicellular, filamentous and spherical fungus. Aspergillus is a septum hyphae with partitions. Mucor also forms island hyphae, but without partitions. Fungal infections can induce the development of granulomas. A feature of fungal infections is vascular thrombosis and widespread tissue necrosis, never manifested in superficial infections. 

Invasive fungal infections of the temporal bone involve the middle ear, submucosal layer and eardrum, and also lead to nerve infiltration in the internal auditory canal, membranous labyrinth, Rosenthal canal with loss of neurons and occlusion of the labyrinth arteries.

Fungal complications of antibiotic therapy. Candidiasis during antibiotic treatment

Dr. Hooman-Khorasani
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Of great interest is the mechanism of development of fungal and inflammatory diseases of the mucous membrane of the respiratory and digestive tracts. Antibiotics with prolonged use cause the phenomenon of dysbiosis and thereby contribute to the development of bacterial and fungal superinfection. Limited and generalized fungal diseases are observed. With limited mycoses, the mucous membranes of the oral cavity, pharynx and larynx are affected. As for generalized fungal diseases, then the mucous membranes of the respiratory, digestive tract and internal organs are affected. These diseases are caused by yeast-like fungi such as Candida albicans.  

Fungi of the genus Candida live on the mucous membranes of the oral cavity and pharynx. They are antagonists of the saprophytic microbial flora there. As long as there is antagonism between different inhabitants, the biological equilibrium established between them is preserved, which characterizes the normal microflora of the oral cavity and pharynx. But this ratio can be broken as a result of the use of antibiotics. Antibiotics suppress the vital activity of microbes sensitive to them, but in this regard, create room for the development of microbes and fungi that are resistant to antibiotic substances. Decreased vital activity or the death of microflora sensitive to antibiotics creates a favorable background for the manifestation of the pathogenic properties of antibiotic-resistant microbes and fungi.  

As for inflammatory diseases of the mucous membrane of the oral cavity and pharynx, these are usually caused by staphylococcal infection, which, as it has been revealed recently, shows significant resistance to the action of various antibiotics (I. G. Akimov, G. F. Gauze, Heinberg – Heinberg – and etc.).  

Side effects associated with the use of antibiotics, we noted in three patients. One patient had dermatitis, another had pharyngeal candidiasis, which developed after intramuscular injection of a large amount of penicillin, and a third patient had inflammation of the oral mucosa and pharynx after taking biomycin tablets. These complications were quickly eliminated by the use of appropriate therapy. 

Antibiotics play and will continue to play a large role in the fight against otogenic meningitis and other infectious diseases. But we should not forget the shady sides of antibiotic therapy, which, however, do not detract from their merits. This fact underlines the importance of the rational use of antibiotics and the prevention of possible complications. 

Treatment of allergic diseases caused by the use of antibiotics consists in the fact that antihistamines are prescribed for such patients: diphenhydramine (0.05 3 times a day), 10% calcium chloride per tablespoon 3 times a day, 10% chloride solution calcium intravenously. Cortisone is prescribed on the first day at 0.1 3 times a day, on the second day – at 0.1 2 times, and starting from the 3rd day at 0.1 1 time per day. Adrenocorticotropic hormone 10-20 IU 3-4 times a day intramuscularly Contraindications for the appointment of cortisone and adrenocorticotropic hormone are hypertension, heart failure, acute endocarditis, gastric and duodenal ulcer. In anaphylactic shock, 1 ml of adrenaline (1: 1000), 1 ml of a 10% caffeine solution, intravenously 10 ml of a 20% solution of calcium chloride are injected subcutaneously and inside of 0.1 diphenhydramine. Limited fungal lesions of the oral mucosa and pharynx caused by a fungus of the genus Candida albicans respond well to the local effects of borax in glycerin.

To do this, take a 10% solution of borax in glycerin to lubricate the affected areas of the mucous membrane. For the same purpose, a 10% solution of boric glycerol, a 1% alcohol solution of malachite greens, and a Lugol solution in glycerin are used locally . Gargling with alkaline solutions (2% solution of soda or borax). With extensive candidiasis, a 3-5% solution of sodium iodide or potassium iodide is prescribed (1 tablespoon 3 times a day); produce 10 injections of a polyvalent yeast vaccine (initially intracutaneously in doses of 0.1-0.2-0.3-0.4, and then intramuscularly at 0.5-0.6-0.7-0.8-1.0). In addition, patients are prescribed treatment with the anti-yeast antibiotic nystatin. Patients take nystatin 2 days for 4 tablets, 2 days for 6 tablets, 2 days for 4 tablets, a total of 28 tablets containing 14 million units. Patients take nystatin and iodine preparations after meals and drink them with milk. In addition, such patients are prescribed ascorbic acid, multivitamins, vitamin K.  

The following measures are recommended for the treatment of complications arising from the endolumbal administration of penicillin: 1) intramuscular injections of lobelin (adults 0.3-0.5 ml, children 0.1-0.3 ml); 2) injections of 1-2 ml of a 20% solution of caffeine (adults); 3) 25-50 ml of a 2% solution of chloral hydrate in an enema; 4) intramuscular injections of a 10% solution of hexenal (adult patients 8-10 ml, children 2-5 ml). 

Some authors, with the aim of preventing complications, recommend giving patients, before subarachnoid administration of penicillin, chloral hydrate in the form of an enema or intramuscularly hexenal.

Fungal diseases (mycoses) in children. Baby otomycosis

Dr. Hooman-Khorasani
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In recent years, an increase in the role of diseases caused by previously less etiologically significant pathogens has been noted , namely, a clear increase in fungal infection in childhood pathology. The high frequency of candidiasis in pregnant women, according to A.S. Ankirskaya, reaching 60%, is the reason for a rather massive infection of newborns during childbirth. 

G. A. Samsygina points out that along with the mucous membranes and skin, the gastrointestinal tract serves as the entry gate for candida with the formation of generalized candidiasis or central nervous system candidiasis. Moreover, generalized candidiasis increased from 1.9% of cases in 1975 to 15.1% in 1995. 

According to V. B. Antonov , an increase in the incidence of visceral mycoses all over the world is accompanied by the formation of especially virulent strains of pathogens, causing not only sporadic diseases, but also massive outbreaks in high-risk groups with a severe course and a fatal outcome. With the development of mycosis under the influence of environmental and iatrogenic causes, a stepwise deepening of immunodeficiency occurs, which predetermines further chronicity of the process and a sequential increase in relapse. The author defines mycoses as diseases of progress and civilization. 

Fungal flora is essential for recurrent and chronic external and middle otitis media. This problem was especially acute after the accident at the Chernobyl nuclear power plant, when a large number of children with disseminated and generalized forms of mycoses appeared. 

Children of a young age are the largest group of risk of fungal infection, particularly Candida. It can occur in acute and chronic form, be a local process, as well as systemic, visceral, generalized and proceed especially hard. 

G. N. Buslaev et al. established the frequency of candidiasis, which ranges from 30-40% among children transferred to the neonatal pathology department. In this case, the diagnosis of candidiasis in the direction of the maternity ward is practically not found. 

The increasing role of fungi in the pathology of ENT organs causes new problems in connection with the development of an atypical clinical picture with a specific course and an increase in the percentage of complicated forms of pathology.  

To date many issues of treatment and prevention remain unresolved. There are problems of late diagnosis. Pathogenetic treatment in these cases is difficult, since the cause of the disease remains unrecognized for a long time. There is no adequate treatment, taking into account the age characteristics of the child’s body.  

The term ” otomycosis ” currently means a fungal disease of the external auditory canal, other parts of the ear, as well as mycosis of the cavities after surgery on the ear (Kunelskaya V. Ya.).
For the first time this disease was described in the middle of the XIX century, in 1844, by the German doctor Mayer. In an 8-year-old girl, a fungus was isolated from a pathological detachable external auditory canal. The second description belongs to the Italian explorer Pacini. Moreover, judging by the description, in both cases there was a fungus of the genus Aspergillus. Then more and more often isolated reports of observations of otomycoses began to appear (Cramer H., Wreden R. R., Hagen R., Bezold F., Politzer A.). A more complete description of this disease, new for that time, was given in the works of R. R. Wreden in 1867 and in the work of F. Siebenmann.  

Russian doctor R. R. Vreden analyzed 14 cases of clinical observations. The causative agents in 10 cases were fungi of the genus Aspergillus. Therefore, mycotic ear disease was called “aspergillus myringomycosis.” In a monograph by F. Siebenmann on mold mycoses of the ear, 27 clinical observations are analyzed. The causative agents were also fungi of the genus Aspergillus. In Russia, in addition to R.R. Vreden, V.P. Ilyin was involved in the studies of otomycosis. Given that in the first studies on otomycosis there was no clear data on the microbiological characteristics of the pathogen, this disease in countries with a temperate climate was unreasonably forgotten.  

In addition, works began to appear from countries with a tropical and subtropical climate, in which the idea was expressed of the direct influence of such factors as a hot climate on the introduction of pathogenic fungi into the outer ear of a person. W. K. Hatch and R. Rou in 1900 recorded 22 cases of otomycosis in 1 month at the Bombay hospital. M. Langeron led a clinical observation of fungal otitis media in Brazil. A.M. Dunlap described several cases of otomycosis in China.  

At the same time , a large number of works by other authors appear, which, studying otomycosis, concluded that increased incidence is observed in countries with hot climates (Bristow WJ, Reeh M. J., Davis, Coghlan C. ZM, Basil-Jones B. M, Lurie H.). In order to emphasize the connection of otomycosis with a hot climate, the authors gave the disease new names: “tropical ear”, “Singapore ear”, “tropical otomycosis”, etc. Based on these clinical observations, they began to believe that otomycosis occurs exclusively in tropical countries. and other descriptions of otomycosis began to be skeptical.  

Only in the 30-40s of our century in Europe again there were cases of a single disease of otomycosis (Motta, Cjill, Ms Burnney, Seaney, Braun, etc.). In all the cases described, the causative agents were fungi of the genus Aspergillus with localization of the process in the area of ​​the external auditory canal. These scientific reports were an incentive for clinicians to a deeper study of the disease (Polyansky L.N., Shea, Brailovsky Y. Z.).   

In the 60-70s of the XX century, in connection with new scientific developments in the field of mycological research, as well as the unreasonable active use of antibiotics, a significant number of works appeared based on dozens of observations (Kunelskaya V. Ya., Lvova S. V., Arya , Mohopatra, Cojocarn et al. Ms. Gill). The first reports of mycotic complications of postoperative cavities after radical surgery on the ear appeared (Preobrazhensky N. A., Cavados, Fendell, Lumsden). 

The most complete description of mycotic lesions of cavities after radical operations on the middle ear in his work “Fungal diseases of the postoperative cavity of the middle ear” is given by N. A. Lev. Having examined 40 patients, the author came to the conclusion that along with the specific clinic characteristic of fungal lesions, fungal diseases of the postoperative middle ear cavity can be observed. The clinical picture of this disease has much in common with non-epidermal cavity of another etiology. Callahan et al. believe that surgical failure during surgery on the ear is often due to a fungal infection not detected before surgery.  

Fungal diseases as occupational diseases

Dr. Hooman-Khorasani
Posted in Uncategorized

Among fungal occupational diseases, aspergillosis and actinomycosis deserve special attention  

Aspergillosis is most often caused by molds Aspergillus fumigatus and niger, and these fungi are pathogenic not only for humans, but also for animals (birds, domestic animals: horses, donkeys, cows, dogs, etc.). When inhaling dust containing fungal spores, the so-called pneumomycosis develops, proceeding as bronchitis (sometimes asthmatic) and recurrent bronchopneumonia. They are found in bakers, flour mills, working elevators and breweries, agricultural workers, carpenters, joiners, feather-pickers, workers in paper spinning mills.

In addition to respiratory diseases, these fungi can cause ulceration of the cornea (usually as a complication of trauma), inflammation of the outer and middle ear, and skin damage.  

Prevention consists primarily in the arrangement of rational dedusting ventilation , personal protection (dust masks, goggles) and compliance with personal hygiene rules.  

Actinomycosis. Called by radiant mushrooms that parasitize plants. These include actinomycetes that live on plants (especially cereals), in soil, and water.

Actinomycetes are pathogenic to humans and cattle. Occupational diseases with actinomycosis are possible in agricultural workers. Infection can occur through the respiratory tract, gastrointestinal tract, and skin. With a broncho-pulmonary form of actinomycosis, a cough with mucopurulent sputum with an admixture of blood is observed. In advanced cases, there may be: a chronic lung abscess, exudative pleurisy, and when the fungus grows into the chest wall – non-healing fistulas. The intestinal form is relatively rare and is also characterized by a tendency to abscess formation and the formation of fistulas.  

When skin lesions are distinguished, gummous, ulcerative and tubercular forms, with painless nodules, which are subsequently softened and opened. Serous-purulent discharge contains yellowish grains – Druze fungus.

In order to prevent the threshing , loading and unloading of grain, the preparation of spinous feed, it is necessary to use dust masks and respirators. Spin feed should be steamed. Sick animals are subject to isolation, and the premises where they were kept are disinfected.  

Fungal diseases of the lungs. Actinomycosis of the lungs

Dr. Hooman-Khorasani
Posted in Uncategorized

Fungal diseases can give a very colorful radiological picture, which can most likely be mixed with chronic tuberculosis processes, cancer and lymphogranulosis atosis. For all chronic, unclear processes that do not respond to sulfonamides, one should think about fungal etiology. 

Actinomycosis of the lungs . It is clinically characterized by an extremely long course of secondary pneumonic processes with fever, mucopurulent sputum, often with leukocytosis. Isolated actinomycosis of the lungs is rare, more often it is also found in other places, especially in the mouth and lower jaw.
The diagnosis is based on the detection of fungi in the sputum, which is repeated in almost all cases with repeated studies. 

In addition to the radiant fungus other fungi may also be etiological factors, but in Central Europe they are very rare. With prolonged treatment with massive doses of antibiotics, they seem to be more common. They should be thought of if, after antibiotic treatment, the picture on the part of the lungs worsens, the intermittent temperature is delayed, and other, more frequent causes of this are excluded. The diagnosis here is made in the presence of fungi in the sputum. We can talk about streptotrichosis, candidiasis (candida albicans), torulopsis, leptotrichosis, aspergillosis, oosporosis, oidiomycosis, in America – blastomycosis (workers in the tobacco industry), coccidiosis and histoplasmosis. With histoplasmosis, foci in the lungs calcify and they must be differentiated from tuberculous dissemination. If fungi are not found, the diagnosis is based on a reaction with an antigen, local and general phenomena, and a positive complement binding reaction (Wegmann).

Fungal diseases can be layered a second time on existing lung lesions (bronchiectasis, cavity formation). Aspergillus-infected lung cysts acquire double contours (Brunner, oral communication). Aspergilloma appears, apparently, as an independent primary lung disease. Aspergilloma can be thought of in the presence of prolonged (months, years) blackouts in the lungs with a good general well-being of the patient and the absence of other causes. Fungal cultures in bronchial secretions obtained by bronchoscopy confirm the diagnosis (Scarinci). Secondary fungal pneumonia with prolonged therapy with cortisone (leukemia, lymphogranulomatosis) are common complications. 

With toxemycosis (Gsell), lung lesions are caused by toxic decomposition products of fungi. Of the clinical pictures of such toxicosis, the most famous is the threshing fever (farmer’s disease), which occurs in persons participating in the threshing of moldy grains – barley or Oats. The disease begins suddenly with fever, headache, cough and basal bronchopneumonia. It is clear that the disease is caused by a fungal infection of the threshed grain.  

Eosinophilic pulmonary infiltrates.

– Löffler’s volatile eosinophilic infiltrate has the following characteristic features. – Volatility : the classic eosinophilic infiltrate should completely disappear after a few days, at most after 10 days. With a longer duration of infiltration, one should be careful with this diagnosis. – Eosinophilia ranges between 7 and 70% with a normal or only slightly increased white blood cell count. Often, eosinophilia is most pronounced not during the highest density of the infiltrate, determined radiologically, but a few days later (phase shift). Sometimes, therefore, it is necessary to re-search for eosinophilia in the blood.  

– Clinically, infiltration can be completely asymptomatic: in these cases, it is found by chance. In other cases, there is an indefinite feeling of some indisposition, especially often pleuritic pains are felt over several days, intensifying with breathing; often there is a slight cough. – Infiltrate has no favorite places of localization. Any parts of the lungs can be affected, and consequently, the tops of the lungs and basal areas. In most cases, the infiltrate is solitary, but there may be multiple infiltrates; infiltrates can also appear repeatedly.  

– In laboratory , in addition to eosinophilia, a slightly accelerated ROE is often observed, but it can be completely normal. – Since with volatile infiltrates in the vast majority of cases we are talking about invasion of roundworms, it is necessary to examine feces on roundworm eggs. But they do not appear during the presence of an infiltrate, but more than 50% after 2 months after the end of the ascaris larvae of their development cycle. 

Eosinophilic infiltrates are found not only with Ascaris invasion, but also with bronchial asthma, in sensitized individuals as a result of hypersensitivity to plants (privet, lion’s tooth, lime blossom, May bell, etc.) ”as well as bacterial allergens. 

Minor eosinophilia may sometimes be accompanied by tuberculous infiltrates, but they are not so volatile and there are other tuberculous manifestations.