P3.M247: Chronic Suppurative Otitis Media due to Aspergillus, Pseudomonas, and MRSA in the Setting of Immunodeficiency and Adverse Drug-Reactions

Introduction: Chronic suppurative otitis media (CSOM) is a condition of persistent middle ear infection and inflammation, typically occurring in early childhood with continuous ear drainage lasting 2 to 6 weeks. Treatment is guided by ear culture results, often revealing Pseudomonas and Staphylococcus aureus as the predominant organisms.

Case Description: A 9-year-old girl was admitted for bilateral otalgia, postauricular pain, and bloody otorrhea from the left ear, raising concern for acute mastoiditis. Her medical history included recurrent otitis media, conductive hearing loss, and B-cell immunodeficiency. She underwent 10 tympanoplasties and missed 42 school days in the last academic year. Plans were in place for mastoidectomies and IVIG.

Upon further review, the patient had been hospitalized multiple times for treatment of chronic otitis media secondary to several drug-resistant organisms and other organisms not commonly associated with otitis media (Table 1). These hospitalizations were complicated by several drug reactions, specifically to anti-fungals (Table 2).

On physical exam, both tympanic membranes were perforated with purulent, non-bloody effusions. Prior CT Temporal Bone with and without contrast was consistent with left otomastoiditis. During admission, cultures were obtained from left ear exudate; and Infectious Disease and ENT services were consulted to assist in the patient’s treatment plan due the complexity of the patient’s history. The hospital medicine team coordinated communication between subspecialties and the family, which enabled family-centered, goal-concordant interventions. This led first to an expedited inpatient mastoidectomy and tympanoplasty. Cultures of the ear exudate grew Aspergillus, and cultures obtained during tympanostomy grew MRSA, both organisms of which have been associated with CSOM, especially in the setting of immunodeficiency. The hospital medicine team subsequently advocated for a trial of oral Posocanazole as recommended by ID while the patient was hospitalized to ensure patient tolerance. She was discharged in good condition on an extended course of Posocanazole and Clindamycin.

Discussion: Chronic suppurative otitis media (CSOM) is a common infectious complication associated with immunodeficiency. Most research on fungal otitis media focuses on adults with advanced HIV/AIDS. One study identified frequent use of topical antibiotics and steroids, swimming, and diabetes as major risk factors. This pediatric CSOM case was complicated by persistent fungal infection and multiple drug reactions, leading to frequent hospitalizations and significant impact on the patient's life. Additionally, her early-onset conductive hearing loss could further hinder social development, compounding her isolation.

Conclusion: Recognizing the patient's complex case and traumatic treatment experience, proactive communication among provider teams was vital in establishing an efficient and conservative treatment plan. Healthcare providers should maintain a high suspicion for fungal infections in immunocompromised patients with chronic ear symptoms, especially when standard bacterial treatments fail or when clinical features are atypical. Early diagnosis and appropriate management are key to improving outcomes in these vulnerable patients.