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,

MN (R.H.).

Correspondence: 4epsteins@comcast.net (S.E.)

CT computed tomography

e110 JAAHA | 47:6 Nov/Dec 2011 ª 2011 by American Animal Hospital Association

any treatment, rhinostomy and topical povidine-iodine dressings or

rhinotomy combined with surgical debridement and topical ad-

ministration of 2% enilconazole may be indicated.4,12,13

Homeopathy is a system of medicine developed by the

German physician Samuel Hahnemann (1755–1843). It is based

on the principle of “let like cure like.” Substances, when tested,

can cause a set of symptoms in healthy individuals that are used to

cure those symptoms (signs in animals) when experienced by sick

individuals. The tests are known as “provings” and are conducted

using dilutions of the original substance.14

One of the first substances tested by Hahnemann was

a preparation of gold, aurum metallicum, in 1818 (six grains

triturated in 100 grains of milk sugar for 1 hr, then 100 grains of

this powder [1 grain of gold] or 200 grains of this powder [2 grains

of gold] dissolved in water [amount not specified] and given orally

to the human provers). This testing, along with his subsequent

prescribing of aurum metallicum to sick individuals (one part of

gold triturated to 100 parts of milk sugar, then one part of this to

100 additional parts of milk sugar, final dilution 1/10,000, given

orally, amount not specified), led him to discover the curative use

of aurum metallicum for painful, ulcerated nasal cavities and

nostrils, nasal congestion, greenish yellow nasal discharge, and

destruction of the palatal and nasal bones.15

The purpose of this report is to describe a case of nasal as-

pergillosis in a dog in which oral administration of homeopathic

aurummetallicum resulted in resolution of signs and disappearance

of the aspergillosis organisms after two noninvasive clotrimazole

infusions had been unsuccessful. This is the first reported case of

clinical resolution of nasal aspergillosis after treatment with aurum

metallicum inwhich follow-up studies were performed to document

the physical changes and clearance of the aspergillosis organisms.

Case ReportA 6 yr old, 33 kg, male, neutered Weimaraner was presented to the

University of Minnesota Veterinary Medical Center (VMC) for

evaluation of a 6–8 mo history of left-sided nasal discharge,

sneezing, and a 3 yr history of episodes of reverse sneezing. The

nasal discharge initially was clear to mucoid, but became purulent

with occasional mild epistaxis approximately 3 mo before pre-

sentation. The clinical signs were unresponsive to treatment with

oral diphenhydramine and clindamycin. During the 4 mo period

before presentation to the University of Minnesota VMC, the dog

became progressively more lethargic, and 1–2 mo before pre-

sentation, he developed a “snapping at flies” behavior accompanied

by continuous licking and crusting of the dorsal nasal planum.

Physical examination on day 1 showed a small amount of

crusting on the dorsal nasal planum, erosion and depigmentation

of the nasal planum, lack of airflow through the left nostril, and

blood-tinged serous nasal discharge on the left side that changed to

a mucopurulent discharge after a bout of sneezing. The left

submandibular lymph node was enlarged. Temperature, pulse, and

respiration were normal (38.88C, 120 beats/min, and 20 breaths/

min, respectively), as was a neurologic examination. A complete

blood count and serum biochemical profile were submitted. The

only significant laboratory abnormalities were hypoproteinemia

(5.2 g/dL; reference range 5.7–7.5 g/dL) and hypoalbuminemia

(2.3 g/dL; reference range 2.7–3.7 g/dL).

On day 2, nasal computed tomography (CT) and rhinoscopy

were performed. Extensive turbinate destruction was identified by

CTa within the rostral and midnasal passages on the left side.

Multifocal, patchy areas of fluid and thickened soft tissue material

were present, predominantly on the left side, but with some similar

appearing material on the right side. There was no evidence of

frontal sinus or maxillary bone destruction. Mild bone thickening

of the lateral ventral aspect of the left frontal sinus was present. The

cribriform plate was intact. Mild left-sided retropharyngeal and

submandibular lymphadenopathy were present. No other abnor-

malities were seen. The diagnostic interpretation was chronic de-

structive left-sided rhinitis and sinusitis with mild right-sided rhinitis

and secondary lymphadenopathy. A fungal disease was suspected;

differentials included aspergillosis and other fungal agents (Figure 1).

FIGURE 1 Nasal computed tomographic (CT) scan on day 2,

before clotrimazole infusion. Increase in soft tissue and fluid density

material as well as loss of normal turbinate architecture are present.

Homeopathic Treatment in Nasal Aspergillosis

JAAHA.ORG e111

Rhinoscopy, using both a 2.7 mm Stortz rigid telescopeb for

proximal visualization and an Olympus Exera II flexible video-

endoscopec for the retroflexed views of the nasopharynx, showed

a thick ropey discharge in the left nasal passage, loss of nasal

turbinates, hyperemia, and edema. Fungal plaques were visible in

the left nasal passages and nasopharyngeal meatus (Figure 2). The

right nasal passage was erythematous and edematous with no

turbinate destruction. Nasal biopsies were obtained with a 2.5 mm

flexible cup forcep biopsy instrumentd passed adjacent to the rigid

telescope. Cytology of the nasal discharge showed a moderate to

marked mixed inflammation (neutrophils, small lymphocytes,

plasma cells) and the presence of fungal organisms 5–8 mm in

diameter; these were basophilic and forming septate hyphae. His-

topathology showed severe fibrinosuppurative rhinitis with marked

infiltrates of neutrophils and debris, large areas of necrosis, and

extensive amounts of fungal organisms characterized by branching

hyphae. A fungal culture yielded growth of Aspergillus spp.

A 1 hr, 1% clotrimazolee infusion was performed according to

standard technique immediately after the CT scan and rhinos-

copy.9 Before the clotrimazole infusion, both nasal passages were

flushed antegrade and retrograde with salinef. Aggressive de-

bridement of visible fungal plaques was not performed, as this was

not known to be essential for treatment success at the time of this

rhinoscopy.4 The dog was discharged later the same day. Five days

later, due to the persistence of the nasal discharge and concern for

secondary bacterial infection, amoxicillin trihydrate/clavulanate

potassiumg was prescribed (11.4 mg/kg PO q 12 hr for 14 days).

On day 38 after the initial examination, the owner reported

recurrence of sneezing and left-sided nasal discharge, which had

ceased entirely for 3 wk immediately after the clotrimazole infusion.

Amoxicillin trihydrate/clavulanate potassium was again prescribed

for 14 days; however, the discharge continued and worsened. On

day 50 after the initial examination, the dog experienced a severe

episode of epistaxis. On day 71 after the initial examination, the dog

presented again to the University of Minnesota VMC with persistent

sneezing, nasal discharge, epistaxis, and facial pain. On the physical

examination performed on day 71 after initial presentation, the dog

was afebrile (38.88C) and had a left-sided serous nasal discharge,

depigmentation of his nasal planum, and crusting on the dorsal

nasal planum. The owner declined a second rhinoscopy before

a second 1% clotrimazole infusion was administered due to fi-

nancial constraints. Clotrimazole was again infused into each nasal

passage as previously performed on day 2. The dog was discharged

with amoxicillin trihydrate/clavulanate potassium (11.4 mg/kg PO q

12 hr for 14 days). One week later, the owner reported a left-sided

thick, yellow, ropey discharge and another episode of epistaxis. The

dog also appeared to be experiencing facial pain.

The dog was re-evaluated on day 115 (44 days after the second

treatment) by SE. A profuse yellow–brown odorous left-sided nasal

discharge was present, which persisted throughout the time after

the second clotrimazole infusion. In addition, the ulceration and

crusting of his nasal planum had progressed (Figure 3). The dog

continued to receive amoxicillin trihydrate/clavulanate potassium

since day 98. The primary care veterinarian gave two refills for 2 wk

FIGURE 2 Nasopharynx on day 2. Retroflexed view with white

plaques obstructing the left choanal area.

FIGURE3 Day 119. Severe ulceration, erythema, and crusting of

the nose of the dog before the aurum metallicum administration and

after two clotrimazole infusions.

e112 JAAHA | 47:6 Nov/Dec 2011

each (total of 6 wk). The dog exhibited pain when chewing and was

acting cold on his walks, wanting to turn around to go home. On

day 119, the homeopathic remedy aurum metallicum 30ch was

prescribed (5 pellets [size #38] dissolved in 15 mL of water PO

once, and then again one time 12 hr later). Improvement was noted

by the owner in the first week. Over the next 3 wk, the epistaxis

episodes ceased entirely, the nasal discharge gradually resolved, and

the dog’s disposition, appetite, and energy returned to normal.

Seven weeks after the homeopathic remedy administration,

the dog presented for a follow-up CT scan and rhinoscopy at the

University of Minnesota VMC.White blood cell count, hematocrit,

platelet estimate, red blood cell and white blood cell morphology,

total plasma protein, and serum biochemical profile were within

normal limits. The previously reported hypoalbuminemia and

hypoproteinemia had resolved (albumin, 2.7 g/dL and total protein,

6.6 g/dL). The CT scan showed that the previously noted turbinate

thickening on the left nasal passage was no longer present. A few

atrophied turbinates were present in the rostral nasal passages, but

the majority of the turbinates in the left nasal passage were com-

pletely absent (Figure 4). In the caudal nasal passages, the ventral

ethmoid turbinates remained, whereas the dorsal turbinates were

absent. The surrounding bone was thickened, and edematous soft

tissue was present at the periphery. The retropharyngeal lymph

nodes appeared normal in size, and the left submandibular lymph

node was only mildly enlarged with respect to the right. These

findings indicated that progressive destruction of the left nasal

turbinates occurred between the first and second CT scans. The

adjacent bone and soft tissue thickening suggested the presence of

residual disease. Rhinoscopy, with a 2.7 mm rigid telescope, verified

the lack of normal turbinate architecture. Minimal hyperemia or

discharge was visible within the left or right nasal passages, and no

fungal plaques were visualized. Mucosal biopsies were taken from

multiple sites in the left and right nasal passages. Histopathology

did not reveal fungal organisms, and mild residual lympho-

plasmacytic rhinitis was present.

Three to 4 mo later, the owners observed a crusty rough

appearance to the dorsal aspect of the dog’s nasal planum, and

a greenish, brownish, yellowish nasal discharge in the morning

that progressed from an occasional drip to a more persistent clear

drainage during the day. They also observed a slight recurrence of

reverse sneezing and the “biting at flies” behavior, both of which

had resolved after the homeopathic treatment. The owners were

instructed to repeat the aurum metallicum as previously pre-

scribed. Within a week of beginning administration of the aurum

metallicum, all of the dog’s abnormal clinical signs resolved,

according to the owner. At follow up on day 965 after initial

presentation, the dog remained asymptomatic, with only an oc-

casional reverse sneeze (Figure 5).

FIGURE 4 Nasal CT scan on day 164, 45 days postaurum

metallicum. Significant loss of nasal turbinates is evident as well as

mild thickening of residual nasal mucosa.

FIGURE 5 Dog’s nose 7 mo after the initial aurum metallicum

therapy. Some permanent remodeling of the left nasal planum is

present.

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DiscussionNasal aspergillosis is a common cause of nasal infection in the dog,

accounting for up to 34% of dogs with chronic nasal disease.1,16,17

Young to middle-aged dolichocephalic and mesaticephalic dogs

are most commonly affected, similar to the dog described in this

report.1 The fungal agent most commonly associated with the

disease is Aspergillus fumigatus, although A niger, A flavus, A

nidulans, and Penicillium sp. are occasionally involved.

Diagnosis of nasal aspergillosis is based on various combina-

tions of diagnostic tests, including diagnostic imaging, rhinoscopy,

sinuscopy, histologic examination, cytology, fungal culture, and

serology.18

In the dog described in this case report, a fungal plaque was

visualized via rhinoscopy and cultured positive for Aspergillus spp.

Fungal elements compatible with Aspergillus spp. were also seen

on cytology and further confirmed from biopsies obtained via

rhinoscopy. CT imaging also revealed changes compatible with

nasal aspergillosis.19–21

Initial treatment consisted of two infusions of topical clo-

trimazole without aggressive debridement. At the time this pro-

cedure was performed in this dog, debridement was not part of the

standard protocol at the University of Minnesota VMC. It is possible

that one reason for this dog’s treatment failure was the lack of

removal of as many fungal plaques as possible during the rhinos-

copy, which was performed only at the time of the first infusion.

A favorable response to conventional therapy is usually in-

dicated by resolution of nasal discharge by 2 wk after therapy.9

Rapid resolution of nasal pain, sanguinous discharge or epistaxis,

and ulcerated nares should occur.1 In some dogs, a mild muco-

purulent, crusty discharge may persist at one or both nostrils,

presumably as a result of the damaged nasal architecture.1 The

dog in this report had a short-lived response after the first clo-

trimazole infusion, but by 5 wk postinfusion, clinical signs re-

curred. The dog showed no response to the second infusion.

Repeat treatment is indicated if the nasal discharge persists by

2 wk after therapy.1,9 An additional clotrimazole infusion was

not performed as the owners elected to pursue homeopathic

treatment.

Homeopathic remedies are prescribed based on the concept of

“let like cure like.” A substance is given to healthy human provers,

who then record their mental, emotional, and physical symptoms

that arise as a result of the remedy’s effects. The symptoms are

collated and recorded in materia medicas and repertories. Symp-

toms and diseases that have been cured by remedies are also

recorded in these texts. These symptoms are then used as indi-

cations for the remedy to be administered when a sick patient

presents with these symptoms (or signs in the case of an animal).

In selecting the appropriate remedy, emphasis is given to signs

that are strong in the case (bone destruction, erosion of the nasal

planum, yellow malodorous nasal discharge) as well as signs that

differentiate one patient from another. Of special importance are

“modalities,” which include anything that makes a patient better

or worse, such as hot/cold weather, hot/cold compresses, time of

day, and seasons of the year.

In this case, the dog’s symptoms resolved after administration

of aurum metallicum, a homeopathic preparation derived from

gold. The dog’s signs of bone necrosis, including head pain, ulcer-

ated nostrils, yellow and malodorous nasal discharge, and aggra-

vation from being cold, corresponded with the signs documented

for aurum metallicum indications in the homeopathic provings and

materia medicas.15,22,23 In this case report, the dog was given a

preparation diluted 1:100, 30 times.

Homeopathic treatment is not fully dependent upon de-

lineation of an etiological agent. The characteristic symptoms

produced by the patient, regardless of the etiological agent, are used

for determining the remedy. However, insofar as certain etiologic

agents are known to produce fixed clinical signs in patients,

knowing that Aspergillus spp. were present in this dog could be

useful in determining the curative remedy. The results of the CT

scans and rhinoscopy, in describing the extent of the pathology in

this dog, were helpful in selecting the curative remedy.

After oral administration of the homeopathic remedy aurum

metallicum, the dog in this report experienced a dramatic clinical

improvement and disappearance of the Aspergillosis organisms.

Homeopathic treatment of nasal aspergillosis has been reported

once previously. 24 The dog in that report had a well-documented

case of nasal aspergillosis and showed an immediate curative re-

sponse to homeopathic therapy using the same remedy as in this

case. Although clinical signs appeared to resolve permanently in

that dog, the report did not include any follow-up studies.24 In the

case described here, follow-up studies, performed 7 wk after the

homeopathic remedy was given and all clinical signs of nasal dis-

charge resolved, showed that turbinate destruction on the left side

had progressed between the first CT, rhinoscopy, and clotrimazole

infusion and the second CT and rhinoscopy. Although the CT ev-

idence supported that the disease continued to progress sometime

between the first and second CT examinations, because the patient

had persistent signs consistent with nasal aspergillosis after a sec-

ond clotrimazole infusion and only showed resolution of disease

activity after the homeopathic remedy, the authors believed most of

the anatomic changes visualized on the second CTreflected damage

that occurred before the homeopathic remedy. The negative fungal

culture and histopathology obtained after the homeopathic remedy

supported that the disease was in complete remission at that time.

e114 JAAHA | 47:6 Nov/Dec 2011

The dog in this case had a mild relapse of signs 5 mo after the

homeopathic treatment. Given the brief and much milder pre-

sentation at that time, no diagnostics were done to verify whether this

was a recurrence of nasal aspergillosis. After the second treatment with

aurum metallicum, the signs promptly and permanently resolved.

The selection of a homeopathic medicine for a specific patient

is based on the patient’s unique characteristic manifestation of the

illness versus the etiological agent. However, as the clinical pre-

sentation of nasal aspergillosis in the dog remains relatively con-

stant, a narrow selection of homeopathic remedies might be useful.

Further pilot studies of the effects of aurum metallicum on nasal

aspergillosis, similar to a recently conducted study that used indi-

vidualized homeopathy to treat pruritus associated with atopic

dermatitis in dogs, are indicated.25 The results of such a study would

help determine the most useful homeopathic remedies for treat-

ment of nasal aspergillosis. Further studies, ideally using double-

blinded, placebo-controlled clinical trials, could then be conducted.

This case report was observational in nature but, in light of the

previously reported case, suggested that further study of the use of

aurum metallicum in cases of canine nasal aspergillosis should be

conducted.

This case report was supported in part by a grant from the Amer-

ican Holistic Veterinary Medical Association.

FOOTNOTESa GE HiSpeed CT/e spiral single-slice scanner; GE Healthcare,

Waukesha, WIb 2.7 mm Storz rigid telescope; Karl Storz Veterinary Endoscopy,

Goleta, CAc Olympus Exera II flexible videoendoscope; Olympus America Inc.,

Center Valley, PAd Flexible cup forcep biopsy instrument; Olympus America Inc.,

Center Valley, PAe Lotrimin; Schering Corporation, Kenilworth, NJf Saline; Baxter Corporation, Deerfield, ILg Clavamox; Pfizer Animal Health, Exton, PAh Boiron, Newtown Square, PA

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