Aspergillus

RE: Aspergillus

Beats — Sat, 23 Oct 2021 16:30:07 GMT

I wonder if the black stuff was congealed necrotic blood?

Rightly or wrongly, I went with continued metacam and doxycycline and itraconazole and give it 2 weeks for any inflammation from my interventions to settle down and see where we are.

RE: Aspergillus

Evelyn Barbour-Hill — Fri, 15 Oct 2021 19:05:59 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233573#233573"] so could do that again. I'm reluctant as I reckon if this was aspergillus, my first treatment would have had a more obviously beneficial effect than it has.[/quote]

Yes, I think that's good reasoning.

This may have become an idée fixe with me, but I'm harking back to the copious black stuff you originally got. I'm still thinking foreign body (and not one small enough to be flushed out, noticed or unnoticed).

RE: Aspergillus

Beats — Fri, 15 Oct 2021 18:47:28 GMT

Thanks Evelyn. Really appreciate your advice and help on this one. I neither wish to euthanase this 4 year old lurcher, nor watch it gradually deteriorate, but I do not have a clear plan in my head at this point.

I coudln't decide if I though neoplasia was less likely or not based on the biopsy. Given, as you say, hard to know what I sampled.

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233572#233572"]I think itraconazole would be a waste of time and money.[/quote]

Thanks. This is not a case for me to waste money on. Although itraconazole is very cheap here (as is the doxycycline). I thought that perhaps after the canestan treamtent already done this may be a reasonable half-way house between further topical canestan application and no further treatment on the aspergillus line of thinking.

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233572#233572"]What was the cream you put in? Canesten? Did you do a soak in Canesten liquid too? Did you put enough cream in?[/quote]

There was a shortage of the canestan liquid, so I only had about 20ml - I used that as a bit of a "pre-flush" for maybe 10 minutes, then stuck 40ml of the canestan cream into the frontal sinus until it was undoubtedly penetrating every communicating part and oozing our of every orifice. This was undoubtedly much more irritant and the face was quite swollen for a number of days afterwards. When I re-flushed a week later (prior to taking the biopsies) I used saline only and cleared the remainder of the cream away. For a case that hasn't cultured aspergillus (fungal and bacterial culture of the initial day were negative) and has nothing more to suggest aspergillus beyond a bad nose and a 1:160 serology titre which I am still somewhat unclear on, I felt this was as far as I should go on that for now with topical applications that may be irritant. I do have 120ml of canestan liquid again now though, so could do that again. I'm reluctant as I reckon if this was aspergillus, my first treatment would have had a more obviously beneficial effect than it has.

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233572#233572"]I'm afraid you have got to brace yourself for rhinotomy, or else get further imaging done.[/quote]

CT/MRI imaging is not an option; I could take an xray myself again, but I'm not sure it will achieve much. The biopsy was a push and is unlikely to be paid off this side of Christmas.

I'm not opposed to a rhinotomy, though I do think I might have given another couple of weeks on NSAIDs and antibacterials/antifungals first just to see that it isn't going to start settling down having flushed aggressively (say if there had been a foreign body and it has been unknowingly cleared, or there was aspergillus and it has been largely dealt with). If for no other reason, it has bled extensively on both occasions I have done something to its nose, a week apart, and it would do no harm to ensure it had a chance to have its rbc and platelet counts as full as it gets before I do a rhinotomy I suspect.

I'll ask the owner if I can post a picture of the dog's face currently as, once again, you might be able to read more into the physical appearance than I can.

RE: Aspergillus

Evelyn Barbour-Hill — Fri, 15 Oct 2021 18:02:42 GMT

Helpful information from the biopsy but it doesn't give you any answers. The only thing is that it looks less likely to be neoplasia now.

The trouble with a blind biopsy is that you have no idea whether the tissue you have taken is the tissue that is going to tell you what you need to know.

I think itraconazole would be a waste of time and money. It's not going to do anything against nasal aspergillosis.

What was the cream you put in? Canesten? Did you do a soak in Canesten liquid too? Did you put enough cream in?

I'd stop the doxycycline too, it's obviously not doing anything.

I'm afraid you have got to brace yourself for rhinotomy, or else get further imaging done.

RE: Aspergillus

Beats — Fri, 15 Oct 2021 15:03:40 GMT

Blind biopsy from level of medial canthus:

Morphological diagnoses:

Chronic active rhinitis with deposition of reactive connective tissue and bone remodelling.

Vascular proliferations.

I spoke with the pathologist who said the tissue sampled appeared to be a reaction to something - that could be the cream I'd put in, aspergillus or something else.

No nose bleeds or nasal dsicharge since last week when flushed through in all directions successfully and pulled these biopsies.

On doxycycline metacam. Think I might add in itraconazole and not flush further presently and see what happens over a few weeks.

I can't decide what I think the most likely thing here is. i don't have a good feeling about outcome.

While discharge and epistaxis has not occurred, swelling under eye and on bridge of nose has progressed a bit and there is some suggestion that the dog may be uncomfortable or irritated by this now.

RE: Aspergillus

ian bates — Wed, 06 Oct 2021 10:17:03 GMT

I have successfully blindly biopsied these previously - pair of haemostats inserted up affected nostril, grab the tissue and pull / tear away. They bleed but then then stop. This technique has given me decent tissue harvests with conclusive results and minimal cost to the client.

Something to consider? (just make sure you measure the haemostat against the nose and mark where the medial canthus is so you don't go too far in and biopsy brain tissue! - apparently that has been done - not by me I hasten to add! )

Good luck

Ian

RE: Aspergillus

Evelyn Barbour-Hill — Tue, 05 Oct 2021 23:16:36 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233454#233454"]

Evelyn Barbour-Hill said:
What happens if you flush the left from the nostril end? Put a big throat pack in, and see what comes out onto it.

I'll try this again on Thursday, but I suspect it might come out the right nostril or whole in sinus if I don't plug it.

[/quote]

Put a thumb over hole in sinus. Put a thumb over R nostril. You're going to need three thumbs!

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233454#233454"]I had a look last week and saw nothing[/quote]

If you saw the choanae and there was nothing there, there was nothing there.

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233454#233454"]There is swelling laterally below eye quite extensive by this point and soft [/quote]

Oh, this sounds bad. Beginning to suggest neoplasia.

If you push a blunt probe (have you got a "groove director with frenulum slit" like every practice used to? We call it Mickey Mouse here) with a certain amount of force in there you may find it goes right through bone into nasal cavity. Down at the bottom of that might be a site to get a biopsy, if it's neoplasia, even if you just suck some tissue out.

But with the history and the black stuff I'm still thinking of foreign body too.

Oh heck, could the black stuff have been black tissue?Melanoma isn't very fragile, but could it have been tissue?

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233454#233454"]

This could be a case for rhinotomy

I'm reluctant to subject the dog to this if is neoplasia.

[/quote]

Yeah. It's a knotty dilemma.

RE: Aspergillus

Beats — Tue, 05 Oct 2021 21:06:27 GMT

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233452#233452"]What happens if you flush the left from the nostril end? Put a big throat pack in, and see what comes out onto it.[/quote]

I'll try this again on Thursday, but I suspect it might come out the right nostril or whole in sinus if I don't plug it.

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233452#233452"]What kind of scope? [/quote]

Flexible endoscope - probably about 4mm, but might be bigger than that. Went as far as the medial canthus. Flushed copiously and did get glimpses and continued to do so as withdrew, and wasn't convinced i could see anything helpful.

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233452#233452"]If you have a flexible endoscope you could have a look from the other end, as it were – you might see something in the choanae.[/quote]

I had a look last week and saw nothing (doesn't mean there is nothing - I'm novice at this).

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233452#233452"]ice cold saline[/quote]

I'll try this. I was going to put some otrivine up as well this week, like I do when cutting stenotic nares.

[quote userid="2131" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233452#233452"]This could be a case for rhinotomy[/quote]

I'm reluctant to subject the dog to this if is neoplasia.

There is swelling laterally below eye quite extensive by this point and soft - i suspect there might be less bone to remove than I would imagine - i'd considered opening this up here and flushing through and through, but when I just stabbed in there last week with no. 11 blade it haemorrhaged badly and I had to just hold pressure on and then apply tissue glue.

Thanks again for advice - very much appreciated.

RE: Aspergillus

Evelyn Barbour-Hill — Tue, 05 Oct 2021 20:40:34 GMT

[quote userid="12930" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/30011/aspergillus/233451#233451"]There is no air flow down the left nostril [/quote]

Well that's not good...

What happens if you flush the left from the nostril end? Put a big throat pack in, and see what comes out onto it.

What kind of scope? Auriscope is better than nothing but a rigid or flexible 4mm endoscope better. When you see nothing but blood, yes, that's a beggar, but flush and flush and flush with ice cold saline and probably eventually you'll catch a glimpse of something.

If you have a flexible endoscope you could have a look from the other end, as it were – you might see something in the choanae.

This could be a case for rhinotomy, but you haven't reached that point yet.

RE: Aspergillus

Beats — Tue, 05 Oct 2021 20:24:56 GMT

Thanks Evelyn! It did mean more to you than it did to me!

I put my scope up and saw blood mainly... I'll try again on Thursday. Any hints?

As you might guess, i don't have MRI/CT...

I thought a good flushing from sinus hole going out through nostril might have helped clear anything given how destructed everything was. It all started reportedly after the dog had its head in a hedge, so a FB was first suspicion. I'd put a 16G foley up behind soft palate and over-inflated the balloon - when I flushed down it it only came down right nostril at the start, but I don't remember if I tried again after flushing from left sinus, so could be blockage between where sinus exits and caudally? There is no air flow down the left nostril when I checked today.

Fungal and bacterial culture negative on the black gunge that came out. Cytology pending, but i dont think i'll hold my breath for anything useful from that.

RE: Aspergillus

Evelyn Barbour-Hill — Tue, 05 Oct 2021 13:39:11 GMT

Left side, near-total destruction of intranasal structures, partly obscured by mucus/discharge/debris. Destruction may have crossed the midline caudally, can't be sure, it's at the very edge of the film.

Suspicion of foreign body, e.g. piece of wood, at 206-207 level, but appearance may be artefactual.

Seriously, I strongly suggest endoscopy (or for MRI fans, MRI if it's available and affordable).

RE: Aspergillus

Beats — Tue, 05 Oct 2021 09:46:58 GMT

29th July:

30th September:

RE: Aspergillus

Beats — Mon, 04 Oct 2021 12:45:11 GMT

Thanks Evelyn. That's most helpful.

I'll post the xray if I can find it in case it means more to you than it did to me!

RE: Aspergillus

Evelyn Barbour-Hill — Mon, 04 Oct 2021 11:08:02 GMT

No greater experts seem to be responding, so I'll do my best.

1. The general view over Aspergillus serology ( in regard to nasal aspergilliosis) seems to have varied over the years from "very unreliable" to "very useful though not conclusive". I think you are right that unreliability would come from false negatives rather than false positives. I think it likely that you can get a positive serology when there is no nasal aspergillosis, because the Aspergillus has invaded some where else. I've not encountered what I can prove to be a false positive – but then, like most clinicians I'd guess, I've only submitted blood for serology when very suspicious already of aspergillosis. I have known a positive result but then been unable to demonstrate aspergillosis either on radiography or endoscopy – that might be a false positive or it might be a failure to detect!

Does that help?

I'm afraid I just go with what the lab veterinarian says as to whether it's "highly suggestive" or "equivocal", because I'm lazy.

2. Aspergillus plaques are dirty white-ish. Copious black material is probably something else. Something is necrotic up there. That doesn't mean aspergillosis is not the original cause, of course. But equally there may be a foreign body.