A 56-year-old man with a 22-packs/year smoking history presented with a 2-month history of intermittent, weekly hemoptysis of approximately one teaspoonful per episode. He had a history of cardiac disease (two heart attacks), insulin-dependent diabetes mellitus, and hypertension. There were no complaints of fever, chills, night sweats, fatigue, gastrointestinal discomfort, or dyspnea; he had never previously experienced hemoptysis. The previous month he experienced a weight loss of 3.15 kg. buy flovent inhaler
Examination revealed an afebrile man with normal vital signs and findings were noncontributory except for expiratory wheezing. There was no occult blood in the stool.
Laboratory analysis revealed a normal blood cell count, electrolytes, and serum creatinine concentration. The serum glucose level was 367 mg/dl. A chest radiograph showed a peripheral lesion in the right lung. Tomography (Fig 4) demonstrated a fungus ball in an excavated nodule. Otolaryngologic consultation revealed no abnormalities. A bronchoscopy was performed showing normal airways. Cultures of bronchial washings and collected sputa grew С immitis. Organisms were not seen on an initial direct specimen examination. Acid-fast bacilli cultures were negative.
Specific treatment was withheld. The patient experienced no further hemoptysis. Radiographically, the cavity collapsed over time with residual nodule formation. One year after presentation, successful and uneventful cardiac bypass surgery was accomplished. He continues to do well 29 months after his original presentation. Clinically, pulmonary coccidioidomycosis is usually symptomless. Four types of radiographic findings have been described: (1) bronchopneumonia, acute and persistent and chronic fibrocavitary disease; (2) cavities (often thin walled); (3) hilar adenopathy; and (4) nodules (coccidioidomas).
The majority of cavities are found through serendipity; 86 percent are single cavities and 14 percent are multiple. The incidence of cavitation has been estimated to be 0.1 percent for symptomatic disease and 1.7 to 8 percent for all cases of coccidioidomycosis. The typical cavity is thin walled without fluid levels. Symptomatic cavitary coccidioidomycosis presents as fever with hemoptysis. Hemoptysis incidence ranges from 23 to 50.6 percent, cough being the most common symptom at 42.7 percent. The majority of cavities resolve spontaneously, 50 percent within 2 years. Winn has observed 27 percent of cavities less than 2 cm in size to close within 2 years. Skin tests to coccidioidin (1:100) are positive in 54 to 70 percent; serologic tests are positive (usually in low titer, less than or equal to 1:4) in 75 to 82 percent, and sputum cultures are positive in 64 percent. Skin test positivity may be increased using higher dilutions of coccidioidin (1:10) or spherulin.
Figure 4. Tomogram of intraparenchymal cavity with fungus ball.