Fungal Allergies and Sinus Issues
Yeast, Candida, Thrush, Monilia, Mold, and Fungus are all terms that we routinely use interchangeably and incorrectly. This is often confusing to both physicians and patients. Mycology is the “study of” fungi and we really have very little of it in medical school. There are really separate pathologic conditions we must differentiate in order to understand the condition. Unfortunately, there is no rule that you cannot have a combination of things affecting you.
Fungal sinusitis is really nebulous term that implies there are fungi creating problems within the paranasal sinuses. By definition there really must be some objective findings on a CAT scan of the sinuses. If indeed there are fungal organisms in the sinuses, these can cause inflammation via a number of mechanisms. First, by the fact that they are sitting there in close contact with our sinonasal mucosa, it is more likely that we develop sensitivities or allergies to them. No matter if there are allergies to the fungi or not, removing them from the sinonasal passages is paramount.
Allergic Fungal Sinusitis
When there are fungal organisms inappropriately occupying the sinuses they will often elicit an allergic response. The CT is often impressive for multiple fungal organisms and the allergy tests seem to correlate. Dr. Bradley Marple and colleagues at Dallas Southwestern really described this condition called Allergic Fungal Sinusitis. The treat ment is meticulous surgical debridement and subsequent allergic desensitization.
Eosinophilic (non allergic) Fungal Sinusitis
Mayo clinic physicians have discovered a non allergic (but immune mediated) inflammatory response to molds which causes sinusitis as well. They have termed this Eosinophilic Fungal Sinusitis. It is primarily Cell Mediated (not IgE Mediated) and seems to be related to a specific mold Alternaria. Again, removing any and all molds and then controlling the immune response is the treatment. They actually propose rinsing the sinonasal passages with antifungal agents.
Invasive Fungal Sinusitis
Invasive fungal disease really is largely limited to immunocompromised patients. We often see these as urgent life threatening conditions on the oncology ward. We immediately try to remove all of the offending fungi, however the survival of the patient is really more dependent on the patient mustering some type of an immunologic response. Whether or not the patient has allergies, it rarely makes sense to desensitize an immunocompromised patient.
Candidiasis and Mold Allergies
Fungi can also cause patients problems even if there sinuses are not loaded with organisms. In these patients, the CAT scan is less impressive and surgery is not in the treatment regimen.
Allergy to molds is a common ailment and can really keep patients miserable on a year round basis. Molds are often airborne20and unfortunately can cause symptoms on a year congestion, and fatigue. They can readily be diagnosed by either skin or blood testing for IgE against each type of mold. Again, removing the fungi and then desensitizing the patient is the treatment.
Candidiasis is really a diagnosis of exclusion, and a questionable one at that. Dr. William Crooks defined the condition as an overgrowth of yeast primarily within our digestive tract that leads to a chronic inflammatory state. It too is treated with elimination of the molds as much as possible, and then setting up conditions to avoid recurrent yeast overgrowth. These treatment options really seem to help a lot of patients, I am just not sure we understand the pathophysiology of what is really going on. In treating these patients we often try dietary manipulation that would preclude fungal overgrowth. This is often a low carbohydrate or gluten free type of diet. I suspect this may be the major reason these people feel better.
Gluten intolerance (Celiac Disease) is probably an under recognized entity. There is certainly a large portion of the population that has some sensitivity to gluten and feels much better avoiding it. Whether or not they meet the criteria for Celiac seems academic.
For whatever reason, many patients seem to get clinical benefit from antifungals, probiotics, and or dietary changes. This makes sense, in that lessening exposure to substances patients are sensitive to, would make them feel better. Likewise, desensitizing them with immunotherapy, also seems to be helpful.