Marion, a university lecturer aged 48 years, presented to her general practitioner complaining of persistent hoarseness for 4–5 weeks. Over the preceding 5 months she had suffered two prolonged episodes of bacterial sinusitis and an infective exacerbation of her asthma, each requiring several weeks of various antibiotics and oral prednisone, and each associated with transient hoarseness. Marion has generally well controlled asthma and has used a medium dose inhaled corticosteroid (fluticasone/salmeterol via dry powder inhaler) for many years. She has also used an intranasal corticosteroid (budesonide 64 μg daily) on a daily basis for 2 years to help control symptoms of rhinosinusitis. She is a lifelong nonsmoker and is otherwise in good health. She rinses her mouth after each inhaled corticosteroid dose. She has no pets and does not live on a farm. The only travel she has done in the past few years is to the United Kingdom to attend a conference. During this trip she did
not travel to any rural areas.
Marion's GP was concerned about the persistent hoarseness and referred her to an ear, nose and throat (ENT) surgeon who examined her lower pharynx and larynx with a fibre optic scope. In his letter back to the GP he described seeing 'a small red nodule' on her left vocal cord at laryngoscopy. There were no other abnormal findings and she was advised to watch and wait.
After several weeks she returned to the ENT surgeon with worsening hoarseness. This time he performed microlaryngoscopy which demonstrated an inflamed, bulky left vocal cord covered with white debris. A biopsy was taken which was reported as growing both Aspergillus and Cryptococcus species. Marion was commenced on itraconazole 100 mg/day oral for 1 month. Despite several weeks of antifungal treatment, her symptoms did not improve. A microbiologist was consulted who suggested repeating the biopsy to reconfirm the pathogen. This second biopsy grew Candida species, and she was changed to fluconazole 200 mg/day oral for 2 weeks and referred to a speech therapist with gradual resolution of her hoarseness over the next 6 months. Marion had a chest X-ray (screening for lung cancer), which was unremarkable, and tests for human immunodeficiency virus (HIV) serology, full blood count and fasting blood glucose, which were all normal.
Marion's asthma had been well controlled for many years on a medium dose inhaled corticosteroid. She was referred to a respiratory physician for an opinion on ongoing management of her asthma and the decision was made to cease her inhaled and intranasal corticosteroids. She was temporarily changed to montelukast sodium 10 mg/day oral, however, this is not subsidised on the Pharmaceutical Benefits Scheme for adult asthma so she did not continue to use it. At the time of writing, she had ceased all her asthma medications and was doing surprisingly well.
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