Rare Fungal Sinus Infection - WWYD?

[shamrock]

Hello, I’m appealing to the wise folks of COTH today, as I’m extremely worried about my boy. He’ll be 17 in April. He is a TB gelding named Crosby that I’ve had since he was 3. I absolutely adore this horse. Words can’t express how much I love him. He has always been so sweet and kind and we’ve had many wonderful years together.

In February, he was diagnosed with a sinus infection. My vet referred us to a surgeon who recommended a sinus flush and it was booked for March 6th. It was to be a common, routine procedure done standing at the farm. When the surgeon attempted to insert the flushing tube through a small opening in Crosby’s skull (middle-left forehead), he encountered an unexpected mass of tough tissue. The Dr. then had to make a much larger opening in the skull, below the first one and fairly close to the left eye. At that point, needless to say, I was extremely shocked and worried. The surgeon then proceeded to start excising piece after piece of a large mass from Crosby’s sinus cavity. There was a lot of blood and I could barely watch. I’m usually not phased watching surgery, but this is my baby, so I was dying on the inside while trying to remain calm outwardly. Once the surgery was over, the sinus was packed with miles of gauze and the openings were sutured and bandaged and catheter placed for flushing. The bleeding subsided within the hour and the packing was removed.

Crosby’s after care involved daily flushing of the sinus cavity with 4L of saline for the first week and every 2nd day on week two. Dressing changes every other day, which involved bandaging his entire head. The poor guy handled everything like a champ, as always, and he seemed to heal up well. But, the nasal discharge he initially presented with came back in very short order.

Meanwhile, the tissue sample had been sent to the lab. The results came back a few weeks later stating that it was a fungal mass. Specifically, Alternaria sp. At that point, my vet said systemic antifungals were “not available” so we would just have to monitor and hope for the best.

Fast forward to now (September) and the discharge has not stopped and is getting increasingly worse. My vet consulted with 3 different surgeons, as she had never heard of this fungus before, let alone seen a case of it in equine sinuses. All surgeons agreed that the best and only course of action at this point is surgery AGAIN. I am so upset. I just can’t believe it. The first surgery was covered by insurance to the tune of $4,600 and this time I’m told it would be a minimum of $7,500 for the CT scan + surgery + systemic antifungals for weeks after, all which will NOT be covered by insurance as the issue is now disqualified from coverage.

They also stated that there is a “fair” chance that after all that, the infection/mass could still reoccur. The vet said that if I don’t opt for the surgery, all we can do is monitor the situation to ensure he is comfortable. He does not currently seem uncomfortable, but he is also very stoic, so how is one to really know for sure? She said that the infection can lead to headshaking syndrome and in rare cases can migrate to the brain.

I am devastated as now I feel like I am facing the unthinkable decision way before I ever thought I would. He’s only 16, but he has been through so much. He was hospitalized for 10 days a few years ago after contracting Strangles. He almost didn’t make it. A year later he had to have surgery for an ethmoid hematoma in the right sinus cavity and endured all that after care/recovery. Then the surgery for the fungal mass this past March and all that after care/recovery. Crosby has also been very arthritic in his hind end since he was about 8 years old. It is well managed and we think he is fairly comfortable since he gets around and up and down well, but he is not sound for anything but light hacking. He has navicular changes in both fronts too. This past month he had two abscesses in the same foot. It feels like I’ve been soaking and poulticing endlessly, but we’re finally winning on that front. I feel horrible for my sweet boy. It’s been an awful lot for him over the years.

So, all that to say I’m am really struggling with the idea of putting him through yet another surgery, considering the uncertain prognosis. I know fungi tend to be very resilient, so I’m extremely hesitant. Of course, if the prognosis was very good and he could likely have another 5 or 10 years of quality life, I wouldn’t hesitate, but that does not seem to be the case. I’m considering having just the CT scan done to see how fast the mass may be regrowing (if at all). I’m hoping maybe at that point the vets could give me some indication of his comfort level. I have always said I will never let him suffer; I will not hesitate to have him humanely euthanized if they think he is in unmanageable pain.

How would you proceed under these circumstances? Any suggestions, help or advice would be greatly appreciated. I have tried to search online for information, but there is not really much out there, as it is rare. There’s a fair bit about Alternaria sp. as a fungus, but not it’s effect on equine sinuses.

Thank you so much for reading all that and any help or advice you might be able to provide.

[Simkie]

I am so very sorry

This doesn’t sound like a horse with 5 to 10 years of quality life left, with his hind end and front end lameness. In your shoes, I would either monitor closely for any indication that quality of life was slipping and plan on euthanizing, or just pick a day in the next weeks/months and schedule it. How does he do over winter? If anything about winter is hard on him, I wouldn’t put him through another.

Big hugs, these things are always so hard.

[2tempe]

Oh wow, you have been through a lot. Were it my horse: I would try to get more specifics on how to know if the horse is comfortable or not. No to the surgery and probably No to the CT scan - if the discharge is getting worse, hard to believe there would be any positive information. Given his history and other issues, I would start to think about euthanasia.
By way of background, I have an older mare - coming 20, who has had years of problems including 2 colic surgeries, suspensory problems both hinds and recently added cushings to the mess. Throw in 3-4 other events not detailed here. So I can relate. I have told my vet that if anything happens that can’t be fixed at the farm, the mare is done and I will stand firm on that.
Hugs to you and your boy, this is not a fun place to be…

[shamrock]

Thanks Simkie. Yes, it is extremely difficult for sure. I am so sad. He does well during the winter. He has an extensive wardrobe and is very well fed and cared for by the owner and staff there. They are very attached to him too and this is almost as hard for them.

Would you go ahead with the imaging first just to see exactly what’s going on in there? I was thinking just to try that so maybe they can give me a sense of his comfort level or how long he might have. Or would it just be a waste of time and money?

[Simkie]

@shamrock

Would you go ahead with the imaging first just to see exactly what’s going on in there? I was thinking just to try that so maybe they can give me a sense of his comfort level or how long he might have. Or would it just be a waste of time and money?

I don’t think there’s any one right answer here, but do think about what imaging will change for you. If you’re making a decision on moving forward with surgery based on the imaging results, then it sounds like something you need. If imaging will make a euthanasia decision easier for you, it could be valuable. A conversation with the vet about what you might see on imaging and what each of those possible outcomes mean moving forward might be helpful?

But there’s certainly expense there, and stress on the horse. Do they have to lie him down for that? I would have some very serious concerns lying down an 16 yo horse with lameness issues everywhere. That alone is a risk.

Even with clothes, cold air may be really uncomfortable for him to breathe, so that’s another thing to consider.

Personally, I would skip the imaging, pick a day sometime in the next several weeks, and euthanize. Spoil him silly, do all the things he loves, feed him all the treats, and let him go. That’s not the only answer out there, and I am so sorry these decisions are so hard. But letting them go while they still feel good when you know things are going to get worse is always a kindness.

[shamrock]

Thanks so much 2tempe. I’m so sorry you have gone through all that will your mare. It really is horribly difficult. I’ve always subscribed to the idea of “a day too early” and never letting him suffer. I’m just struggling so much because I don’t want to do it too early if he is fairly comfortable, obviously. I just hope the vets can give me some idea as to how to do that. I was thinking about maybe doing the imaging so maybe they could give me a better indication of his current comfort level.

[shamrock]

I guess I’m just desperately grasping at straws with the imaging idea trying to make sure I don’t let him go too early, but you’re absolutely right, the imaging itself may be very stressful for him. I don’t know if they have to lay him down for it. I have a bunch of questions in to my vet about all of it, so I’m just waiting for her reply. And you make a good point about the cold winter air. Thank you, I hadn’t even considered that.

[sascha]

The posters above have likely given you the best answers.

I will add another. Not necessarily something I would push for with this particular horse, but maybe its something you need to do for your own closure as a sort of hail Mary.

Head rads to get a current picture. Obviously it won’t be the quality of a scan but it may be enough to get an idea of how the thing is growing/stagnating/reducing. Push hard for as high a dose as possible of systemic antifungals and keep the horse on them for 2 months. Re-take the head rads. Make a decision.

If at any time during the ‘drug trial’ there is ANY decrease of quality of life, PTS with no further intervention.

Is this likely to work? Probably not. But it would give you a time frame that ends before winter truly sets in, a Hail Mary, and probably not make the horse worse, and if it did, you’ve got a plan in place with a hard cut off for any decrease in quality of life. It also gives you 2 months to decide what to do if there is no decrease in quality of life and no growth of the lesion.

Where did this idea come from? I almost put my horse down last year for a would not effing quit sinus infection. (caveat, not fungal) I pushed hard, I called in every favour I could and I put my horse on ABX for 2+ months straight. The recurring infection, that would get a lot better (appear to be cured) and come back roughly 6-8 weeks after the end of a 10-14 day cycle of drugs, has not (KNOCKING ON WOOD SO HARD) come back in almost a year now. Sometimes I think we forget that long(ish)-term drug therapy can be a thing.

[2tempe]

The difference between your situation and mine is that I do not have a strong emotional attachment to this mare. I sometimes feel crappy when I say it, but it is reality.

I like the idea of head rads if the vet(s) think they can get some info. It certainly would be less out of pocket.

[RedHorses]

Been there, done that sort of thing… twice.

I get it. You feel cheated because horses are supposed to live into their twenties, not face terminal issues at 17 (or 18… or 15 ).

My second horse was 11 when he retired, 18 when I euthanized. My 15yr old fourth horse, who was supposed to be my main mount for ten years after my third horse passed… well, it looks like he’s going before my third horse.

But here’s the thing - if you see him regularly you already know how he’s doing, how much pain he’s in, what his quality of life is. You just have to let yourself see it. It’s a really hard thing to do - an awful, horribly difficult thing.

We want to keep our dear friends around so much, that we don’t want to see the slide into enduring life. We ask other people how much is too much, when is it time, how do we know. But that’s our way of protecting ourselves - we don’t want to have to make the ultimate decision. We question what we see, and ask if we’re trying to justify a decision - either way.

I made the decision to euthanize my first horse (aged 26) back before we talked openly about it. It was the hardest thing I’d ever had to do up to that point. Some years later (too few) when I had to make the decision for my second horse, we were starting to talk openly about it on bulletin boards and in real life. I started a blog about it, hoping to let others know they weren’t alone, and to share the lessons learned. This post is the summary (please read it):

When do you know it’s time? The toughest decision of all

Fourteen years later I’m in that same position again, with an even younger horse. I’m thinking about adding to the blog. This time I’m facing it with a vet I’ve known for less than a year. And it’s a much less clear cut situation.

Can I offer virtual (((hugs)))? Trust yourself.

[NaturallyHappy]

@sascha, I’m so glad you posted this. This could really help the OP come to a comfortable decision w her beloved horse. Thank you for the idea.

[shamrock]

Thank you so much sascha. I actually had another set of rads done about a month ago and all they show is the same cloudyness in the left sinus cavity that he had before we opted for the surgery in March. Before I got the news from my vet this past Friday, I was hoping she would be able to put him on the systemic antifungals and see if they would help, but the vet said that all three surgeons she consulted with said they would absolutely not advise putting him on just the antifungal treatment without going in to fully debride the area surgically. They said past cases in which antifungals only were tried did not yield a positive outcome. Also, they would cost $130 / day so the cost is extremely prohibitive.

I’m so glad to hear your horse pulled through from what you were dealing with. Bless you both and all the best.

[shamrock]

That’s completely natural 2tempe. Sometimes we have deeper connections with some than with others.

Yes, we did do another set of rads about a month ago and they show the same cloudyness in the left sinus cavity as he had before the surgery in March

[beowulf]

I am so sorry to hear you are going through this. I had a friend go through something similar. Sinus infections SUCK. They are so difficult to eradicate.

I have no advice , just lots of hugs and commiseration. Please give Crosby a peppermint from me. I’m so sorry you’re faced with thinking of the unthinkable.

[shamrock]

Thank you so much RedHorses. Huge hugs right back to you. It sounds like you have been through some very hard times with your horses over the years too.

You are absolutely right. I had visions of him living happily well into his twenties, when in reality he was basically semi-retired by the time he was 12. This decision is really messing with my mind because when he’s standing in front of me I see my beautiful boy with “nothing wrong”, as in, he looks just fine. So when my brain tries to process having to put him down it’s very guilt-inducing. Logically and clinically I realize he is not okay and it needs to happen, but my heart has other ideas. The battle between heart and mind is fierce. I just have to keep trying to assure myself that it’s the kindest and fairest thing for him. I will never let him suffer.

Thank you so much for sharing your blog. I will definitely read it. All the best to you for many happy horse years ahead.

[shamrock]

Thank you so much for your kind words of support beowulf. It really means a lot to me. My heart is already shattered just thinking of “the day”, so I’m afraid of what life will be like when he’s gone. He’s been like therapy for me over the years. He’s my happy place during rough times. I’m sure it’s like that for so many of us.

[shamrock]

A pic of me and my sweet prince in happier days.

[OzarksRider]

If you can afford it, get an opinion from one of the vet schools you mentioned. I think this is the best thing you can do to give yourself confidence that whatever decision you make is the best one for Crosby.

Alternaria is actually a very common fungus, and it is a well known plant pathogen. It can cause sinus infections in humans, although this is rare. When it does cause an infection, it is usually in patients with a compromised immune system. It would be worthwhile to ask your vet if there is any reason Crosby might have a deficient immune system, from Cushings for example.

[shamrock]

Thank you Ozarks. Yes, one of the three opinions my vet got was from a surgeon at OVC at the University of Guelph. They were of the very firm opinion that the area needs to be fully surgically debrided prior to any systemic antifungals being prescribed. They maintain that they would have little to no effect without surgery and at $130 / day the cost is very prohibitive.

I did some reading about Alternaria sp. of course, and yes, it is a very common fungus in our environment. The problem is that it is exceedingly rare for it to invade equine sinuses, so I have yet to find any information specific to his case out there.

I wonder if the university might be interested in studying my boy’s case?

[starsandsun]

I’m so sorry you’re faced with this. I read your post with dread because I was recalling a similar case with an acquaintance and very beloved young horse. Despite repeated surgeries (4, I think?), they could never get the fungal infection under control and eventually they had to make the decision he could not recover. As others have posted, with recurrent challenges and persistent arthritis for many years, it is impossibly hard but you’re going to do the right thing when the time is right. I wouldn’t put him through more surgery or exploratory work but instead look to keep him as comfortable as you can for as long as you can.