CASE REPORTS Clinical Resolution of Nasal Aspergillosis Following Therapy with a Homeopathic Remedy in a Dog Shelley Epstein, VMD, Robert Hardy, DVM, MS, DACVIM ABSTRACT A 6 yr old, male, neutered Weimaraner was treated homeopathically for nasal aspergillosis after failing to respond to two treatments of topical (intranasal) clotrimazole and oral amoxicillin trihydrate/clavulanate potassium. Computed tomography, rhinoscopy, fungal culture, and cytology previously confirmed the diagnosis. At presentation for homeopathic treatment, the dog had aggressive left-sided sinusitis and rhinitis with destruction of nasal turbinates and severe bouts of epistaxis. Erosion and depigmentation of the nasal planum were evident. After two treatments with homeopathic aurum metallicum, resolution of clinical signs occurred and clearance of the aspergillosis organisms was documented by computed tomographic scan, rhi- noscopy, and histopathology. Homeopathic aurum metallicum may be beneficial in treating cases of canine nasal aspergillosis. (J Am Anim Hosp Assoc 2011; 47:e110–e115. DOI 10.5326/JAAHA-MS-5560) Introduction Aspergillosis is a common cause of nasal infection in the dog, affecting between 12% and 34% of dogs evaluated for chronic sinonasal disease. 1 It can cause a profuse mucopurulent to hem- orrhagic nasal discharge, sneezing, reverse sneezing, ulceration of the external nostrils, facial pain or discomfort, destruction and necrosis of the nasal mucosa and underlying turbinate bones, and frontal sinus osteomyelitis. 1–3 Effective, noninvasive, safe, and inexpensive treatment of dogs diagnosed with nasal aspergillosis is challenging. Oral administration of antifungal agents such as thiabendazole, ketoconazole, itraconazole, and fluconazole, al- though noninvasive, requires prolonged administration due to poor to moderate efficacy. 4–8 In addition to the high cost of these drugs, side effects such as hepatotoxicosis, anorexia, and vomiting are commonly reported. 7 Clinical cure is reported in approxi- mately half of the patients treated with thiabendazole and keto- conazole, and in as many as 70% of patients treated with itraconazole or fluconazole. 4 A topical 1 hr infusion with clotrimazole is considered an effective noninvasive treatment that carries a 65% success rate after one treatment and an 86–87% success rate with one or more applications. 9,10 More recently, endoscope-assisted debridement followed by endoscope-assisted infusions with 1% or 2% enilco- nazole were evaluated. The overall success rate of treatment of dogs in either group (9 of 19 [47%] cured after one infusion, 6 of 19 [32%] after two infusions, and 2 of 19 [11%] after three infusions of 1% enilconazole [total 89%]; 6 of 7 [85.7%] cured after one infusion; the remaining dog cured after a second in- fusion of 2% enilconazole) was similar to that previously reported for noninvasive topical infusions. 3 Another recent study evaluated the efficacy of a 5 min flush of 1% clotrimazole delivered via frontal sinus trephination followed by instillation of a 1% clo- trimazole cream. Twelve of the 14 dogs (86%) responded well to treatment and either had no clinical signs after treatment or had signs consistent with mild rhinitis during a minimum follow up of 6 mo. Only one dog required multiple treatments. 11 This treatment protocol, although offering comparable success rates and shorter anesthesia than intranasal infusions of either clo- trimazole or enilconazole delivered via catheters, is more invasive and carries additional expense. For dogs that remain refractory to From the Wilmington Animal Hospital, Wilmington, DE (S.E.); and College of Veterinary Medicine, University of Minnesota, St. Paul, MN (R.H.). Correspondence: [email protected] (S.E.) CT computed tomography e110 JAAHA | 47:6 Nov/Dec 2011 ª 2011 by American Animal Hospital Association
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Clinical Resolution of Nasal Aspergillosis Following Therapy With a Homeopathic Remedy in a Dog
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CASE REPORTS
Clinical Resolution of Nasal AspergillosisFollowing Therapy with a HomeopathicRemedy in a DogShelley Epstein, VMD, Robert Hardy, DVM, MS, DACVIM
ABSTRACTA 6 yr old, male, neutered Weimaraner was treated homeopathically for nasal aspergillosis after failing to respond to two
treatments of topical (intranasal) clotrimazole and oral amoxicillin trihydrate/clavulanate potassium. Computed tomography,
rhinoscopy, fungal culture, and cytology previously confirmed the diagnosis. At presentation for homeopathic treatment, the
dog had aggressive left-sided sinusitis and rhinitis with destruction of nasal turbinates and severe bouts of epistaxis. Erosion
and depigmentation of the nasal planum were evident. After two treatments with homeopathic aurummetallicum, resolution of
clinical signs occurred and clearance of the aspergillosis organisms was documented by computed tomographic scan, rhi-
noscopy, and histopathology. Homeopathic aurummetallicummay be beneficial in treating cases of canine nasal aspergillosis.
(J Am Anim Hosp Assoc 2011; 47:e110–e115. DOI 10.5326/JAAHA-MS-5560)
IntroductionAspergillosis is a common cause of nasal infection in the dog,
affecting between 12% and 34% of dogs evaluated for chronic
sinonasal disease.1 It can cause a profuse mucopurulent to hem-
orrhagic nasal discharge, sneezing, reverse sneezing, ulceration of
the external nostrils, facial pain or discomfort, destruction and
necrosis of the nasal mucosa and underlying turbinate bones,
and frontal sinus osteomyelitis.1–3 Effective, noninvasive, safe, and
inexpensive treatment of dogs diagnosed with nasal aspergillosis is
challenging. Oral administration of antifungal agents such as
thiabendazole, ketoconazole, itraconazole, and fluconazole, al-
though noninvasive, requires prolonged administration due to
poor to moderate efficacy.4–8 In addition to the high cost of these
drugs, side effects such as hepatotoxicosis, anorexia, and vomiting
are commonly reported.7 Clinical cure is reported in approxi-
mately half of the patients treated with thiabendazole and keto-
conazole, and in as many as 70% of patients treated with
itraconazole or fluconazole.4
A topical 1 hr infusion with clotrimazole is considered an
effective noninvasive treatment that carries a 65% success rate after
one treatment and an 86–87% success rate with one or more
applications.9,10 More recently, endoscope-assisted debridement
followed by endoscope-assisted infusions with 1% or 2% enilco-
nazole were evaluated. The overall success rate of treatment of
dogs in either group (9 of 19 [47%] cured after one infusion, 6 of
19 [32%] after two infusions, and 2 of 19 [11%] after three
infusions of 1% enilconazole [total 89%]; 6 of 7 [85.7%] cured
after one infusion; the remaining dog cured after a second in-
fusion of 2% enilconazole) was similar to that previously reported
for noninvasive topical infusions.3 Another recent study evaluated
the efficacy of a 5 min flush of 1% clotrimazole delivered via
frontal sinus trephination followed by instillation of a 1% clo-
trimazole cream. Twelve of the 14 dogs (86%) responded well to
treatment and either had no clinical signs after treatment or had
signs consistent with mild rhinitis during a minimum follow up
of 6 mo. Only one dog required multiple treatments.11 This
treatment protocol, although offering comparable success rates
and shorter anesthesia than intranasal infusions of either clo-
trimazole or enilconazole delivered via catheters, is more invasive
and carries additional expense. For dogs that remain refractory to
From the Wilmington Animal Hospital, Wilmington, DE (S.E.); and
College of Veterinary Medicine, University of Minnesota, St. Paul,
Infectious diseases of the dog and cat. 2nd ed. Philadelphia: WBSaunders Co; 1998:404–9.
2. Davidson AP, Pappagianis D. Treatment of nasal aspergillosis withtopical clotrimazole. In: Bonagura JD, ed. Kirk’s current veterinarytherapy XII small animal practice. Philadelphia: WB Saunders Co;1995:899–901.
3. Zonderland JL, Stork CK, Saunders JH, et al. Intranasal infusion ofenilconazole for treatment of sinonasal aspergillosis in dogs. J AmVet Med Assoc. 2002;221:1421–5.
4. Peeters D, Clercx C. Update on canine sinonasal aspergillosis. VetClin North Am Small Anim Pract. 2007;37(5):901–16, vi.
5. Harvey CE. Nasal aspergillosis and penicilliosis in dogs: results oftreatment with thiabendazole. J Am Vet Med Assoc. 1984;184(1):48–50.
6. Sharp NJ, Sullivan M. Use of ketoconazole in the treatment ofcanine nasal aspergillosis. J Am Vet Med Assoc. 1989;194(6):782–6.
7. Legendre A. Antimycotic drug therapy. In: Bonagura J, ed. Kirk’scurrent veterinary therapy XII small animal practice. Philadelphia:WB Saunders Co; 1995:327–31.
8. Sharp NJH, Harvey CE, Obrien JA. Treatment of canine nasalaspergillosis/penicilliosis with fluconazole. J Small Anim Pract. 1991;32:513–6.
9. Davidson AP, Mathews KG. CVT update: therapy for nasal as-pergillosis. In: Bonagura JD, ed. Kirk’s current veterinary therapyXIII small animal practice. Philadelphia: WB Saunders Co; 2000:315–7.
10. Smith SA, Andrews G, Biller DS. Management of nasal aspergillosisin a dog with a single, noninvasive intranasal infusion ofclotrimazole. J Am Anim Hosp Assoc. 1998;34(6):487–92.
11. Sissener TR, Bacon NJ, Friend E, et al. Combined clotrimazoleirrigation and depot therapy for canine nasal aspergillosis. J SmallAnim Pract. 2006;47(6):312–5.
12. Pavletic MM, Clark GN. Open nasal cavity and frontal sinus treat-ment of chronic canine aspergillosis. Vet Surg. 1991;20(1):43–8.
13. Claeys S, Lefebvre JB, Schuller S, et al. Surgical treatment of ca-nine nasal aspergillosis by rhinotomy combined with enilconazoleinfusion and oral itraconazole. J Small Anim Pract. 2006;47(6):320–4.
14. Hahnemann S. Acquiring a knowledge of medicines. In: O’ReillyWB, ed. Organon of the medical art. Redmond, Washington: Bird-cage Books, 1996;72–3, 152–61.
15. Hahnemann S. Aurum metallicum. In: Materia medica pura. NewDelhi: B. Jain Publishers (P) Ltd; 2007;179–97.
19. Burk RL. Computed tomographic imaging of nasal disease in 100dogs. Vet Radiol Ultrasound. 1992;33:177–80.
20. Saunders JH, van Bree h. Comparison of radiography and computedtomography for the diagnosis of canine nasal aspergillosis. VetRadiol Ultrasound. 2003;44(4):414–19.
21. Mathews KG, Koblik PD, Richardson EF, et al. Computed tomo-graphic assessment of noninvasive intranasal infusions in dogs withfungal rhinitis. Vet Surg 1996;25(4):309–19.
22. Boericke W. Aurum metallicum. In: Homoeopathic materia medicaand repertory. New Delhi: B. Jain Publishers Pvt. Ltd; 1995:96–9.
23. Hering C. Aurum metallicum. In: The guiding symptoms of ourmateria medica. New Delhi: B. Jain Publishers, Pvt. Ltd; 1994:270–91.
24. Epstein SR. Nasal aspergillosis treated homeopathically in a dog.J Am Hol Vet Med Assoc. 2006;25:9–16.
25. Hill PB, Hoare J, Lau-Gillard P, et al. Pilot study of the effect ofindividualised homeopathy on the pruritus associated with atopicdermatitis in dogs. Vet Rec. 2009;164(12):364–70.