The Fungal Side of Sinusitis

The Fungal Side of Sinusitis

       The Role of Anti-fungal Agents

by Dr. Andrew Pugliese

A 39-year-old female presented to my office several weeks ago with a history of recurrent chronic sinusitis. According to the patient, her symptoms of chronic sinusitis were pretty much persistent and that multiple courses of antibiotics would improve her symptoms but, she never would feel well. DNA analysis performed by her otolaryngologist confirmed the diagnosis of allergic fungal sinusitis with Epicoccum nigrum. Prior to the patient’s DNA analysis in addition to antibiotic therapy, the patient also received systemic and topical steroids and the patient was also tried on a combination of topical antibiotics and steroids.

Epicoccum nigrum is considered one of the toxicogenic black molds. Other molds in this category include Alternaria and Pullularia. Toxigenic molds have been associated with a variety of symptoms including both respiratory and neurologic in nature. Epicoccum has been associated with both upper and lower respiratory tract disease and has been associated with allergic fungal sinusitis. Based on this patient’s particular history, she was started on oral ketoconazole 200 mg/day. Within a 10 day period time of starting the ketoconazole, the patient had noticed a significant improvement in her symptomatology much greater than what she had seen with antibiotic therapy. The big question is

Why did the patient improve on antibiotics?

The reason for the improvement on antibiotics is related to the secondary bacterial infections that allergic fungal sinusitis creates. Our sinus cavities are normally colonized with bacteria; however, we are not all walking around with sinus infections. This is because the mucosal lining of our sinus cavities provides an excellent barrier to the bacteria and doesn’t allow the bacteria to get into deeper layers and begin to proliferate.

Infections develop when the mucosal integrity of the sinus cavities is disrupted.

Inflammation is a risk factor for disrupting mucosal integrity. With the inflammation that is seen with allergic fungal sinusitis, disruption of the mucosal lining allows for bacterial proliferation and subsequent infections. This is very similar to what happens when our skin is scraped. Our skin is covered with bacteria, yet the skin acts as an excellent barrier to prevent us from having bacterial infections. If there is damage to the skin and there is a wound, which is not cleaned, we develop an infection. This is basically the same that happens in our sinus cavities. Chronic inflammation allows for the proliferation of bacteria and subsequent infections. Herein lies why the patient experienced some relief with antibiotics.

Unfortunately, in this case, the major underlying risk factor was not being addressed properly. Steroids have long been a major adjunct in treating allergic fungal sinusitis, and there are those who still believe that the treatment of choice for allergic fungal sinusitis is steroids. Steroids, however, only reduce the inflammation and the benefit of steroids is only seen while the patient is on steroid therapy. In many instances, symptoms return after steroids are stopped just like as seen with antibiotics.

There are those patients that have been diagnosed with allergic fungal sinusitis that do too well with topical steroid therapy. However, the majority of these patients have recurrent symptoms despite steroid therapy.

The delivery method for this therapy can be topical, orally or intravenously. The delivery method should be based on the severity of disease where the intravenous use of antifungals should be limited to patients with extensive or invasive disease. Once the patient is stable a maintenance regimen needs to be tailored to the individual patient.

Allergic fungal sinusitis, in my opinion, is very much underdiagnosed here in the United States. This is because up until the time of DNA analysis growing fungus by routine culture technique was extremely unreliable. DNA analysis will allow us to identify allergic fungal sinusitis in patients with chronic sinusitis that has been refractory to conventional therapy and allow clinicians to treat these more difficult cases better.

By | 2020-01-14T11:21:44-05:00 May 7th, 2018|Antibiotics, Chronic Sinusitis|

About the Author:

I am a passionate blogger, author, speaker and 3X Board Certified MD in Infectious Disease, Internal & Sleep Medicine. I currently am an infectious disease physician in Atlanta, GA for Infectious Disease Consultants.


  1. Ronoh Ronoh June 10, 2015 at 4:49 am - Reply

    That is true . better diagnostic method for better treatment of fungal sinusitis.

  2. Lauren June 10, 2015 at 2:27 pm - Reply

    Wow, great post! Thanks for sharing this valuable information and insight about the fungal side of sinusitis.

  3. Lilian Sarah Kong'ani June 15, 2015 at 9:38 am - Reply

    The information on the fungal side of sinusitis is much appreciated.

  4. Rosy June 18, 2015 at 2:35 am - Reply

    I love this blog, quite a lot to learn from, thanks and keep sharing. This is definitely making an impact on the health of many.

  5. frances phelan June 27, 2015 at 4:48 am - Reply

    I cleaned a hospital for 6 years…..started having weird head problems a year after i left….apparently i have a bent sputum (problaby from been hit in nose from cricket ball 30 years ago) and have sinitus accorinding to a CT scan…..steoird nose spray was effective after a week which i still use now…..

  6. Adam @ September 15, 2015 at 2:20 pm - Reply

    What is your prescribed steroid / antifungal prescription for long-term care?

  7. Yang March 8, 2019 at 9:38 pm - Reply

    I have sinusitis all my life and sometimes it really frustrates me. Thank you so much for sharing this information!

  8. Dr. Andrew Pugliese April 4, 2019 at 5:23 pm - Reply

    Thank you so much for reading! Glad you found that article insightful! Make sure to sign up to receive future blog posts via my newsletter sign up!

  9. Enrique Pasion June 28, 2019 at 8:51 pm - Reply

    Since I was young have always been plagued by sinusitis headaches and never knew the fungal side to this condition. Thank you for sharing this information.

    • admin July 2, 2019 at 2:07 pm - Reply

      Thank you for reading the blog! Really glad you found the article insightful.

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