To the Editors:
Scedosporium apiospermum is a rare cause of infection, particularly in immunocompetent hosts. Localized infection with S. apiospermum can progress to cause serious sequelae such as brain abscesses and osteomyelitis. We report a rare case of S. apiospermum otomycosis in an immunocompetent 4-year-old male with chronic otorrhea and otitis media.
This patient had multiple episodes of otitis media since 8 month old that were treated with several short courses of antibiotics, including oral amoxicillin, oral cefdinir, topical ciprofloxacin-dexamethasone, topical ofloxacin and topical gentamicin. Due to recurrent ear infections and conductive hearing loss, bilateral tympanostomy tubes were placed at 22 month old. These were replaced after 5 months due to persistent symptoms and displacement of the right tube. The patient continued to have intermittent right otorrhea with pruritis for the next 2 years, treated with a combination of oral and topical eardrops before being re-evaluated by his otolaryngologist. He was found to have a retained tympanostomy tube in his right ear canal with large amounts of white debris that was cultured and grew Scedosporium sp. not prolificans. The retained tube was replaced with a Duravent tympanostomy tube, but the otorrhea continued.
We prescribed clotrimazole topical drops to be used three times a day for 14 days due to a repeat positive culture with S. apiospermum. The isolate was susceptible to amphotericin (minimum inhibitory concentration, MIC 2 mg/mL), itraconazole (MIC 2 mg/mL), posaconazole (MIC 1 mg/mL) and voriconazole (MIC 0.5 mg/mL). According to a telephone encounter with the patient’s mother, 2 months after the treatment visit, the patient’s symptoms of pruritis, otalgia and otorrhea resolved within the first week of antifungal therapy. Four months after this treatment course, he had an episode of otorrhea that was not cultured, but was successfully treated with ofloxacin eardrops, implying a bacterial cause. He has subsequently been free of ear infections.
Otorrhea due to fungal organisms is often discovered after multiple oral and topical antibacterial medications have been used. Before a fungal ear culture was collected on our patient, he had had 10 visits with his primary care provider and 5 visits with his otolaryngologist, with multiple courses of topical antibiotics prescribed without specific cultures. Even after S. apiospermum was initially cultured, no specific therapy was provided until referral to the Infectious Disease clinic.
One other documented pediatric case of otitis externa caused by S. apiospermum in an immunocompetent 8-year-old child was successfully treated with surgical debridement and topical clotrimazole.1 The patient described had chronic otorrhea that was diagnosed as S. apiosperumum infection after surgical management and antibacterial therapy. Our case supports the use of monotherapy with topical clotrimazole for the treatment of S. apiospermum otitis externa. It also indicates that chronic otorrhea refractory to surgical and antibacterial therapy should prompt a search for atypical organisms and fungi. Although Scedosporium sp. otitis externa and media are rare in immunocompetent children, its early diagnosis and management are important to prevent severe complications.
The authors thank Bhavani Vishwanath for providing assistance with the identification of the organism.
Wei Li Adeline Koay, MBBS
Chelseá Briana Johnson, BS
Janak Patel, MD
Lemuel Ose Aigbivbalu, MD
Department of Pediatric Infectious Disease
The University of Texas Medical Branch
1. Bhally HS, Shields C, Lin SY, et al. Otitis caused by Scedosporium apiospermum in an immunocompetent child. Int J Pediatr Otorhinolaryngol. 2004;68:975–978