Cavitary Coccidioidomycosis With Fungus Ball Formation: Discussion

The indications for surgical removal of a cavity are variable and include the following: (1) rapidly expanding cavity (> 4 cm) close to visceral pleura with risk of imminent rupture; (2) serious or persistent hemoptysis; (3) symptomatic fungus ball; (4) bronchopleural fistula; (5) persistence greater than 1 year; and/or (6) culture-positive sputum. Underlying host compromise, including diabetes, has been proposed as mandating surgical removal. Surgical removal should not be undertaken lightly, as the complication rate is high (30 percent bronchopleural fistula) and recurrence is not uncommon (18 percent recurrent cavities ). Of four deaths in one series, two were related directly to surgery. Smith et al have stated that in the absence of a definite indication, the patient should be left alone with the cavity. If surgery is contemplated, amphotericin В has been recommended as the complication rate has been observed to be reduced (4.2 percent vs 20.4 percent). buy claritin online

Although initially described in 1946 by Forbes and Besterbreutze, the presence of hyphae of С immitis in pulmonary cavities remains a rare phenomenon. Hyphae were visualized in only 1 of 95 pathologic specimens analyzed in the series of Forbes and Besterbreutze and no spherules were observed. The coexistence of spherules and hyphae was first described by Bass et al in 1946. Other examples of mixed hyphal/spherule elements have been alluded to without good documentation. The incidence of hyphal forms occurring in pulmonary cavities was found to be 73 percent and in granulomas (coccidioidomas) it was found to be 30 percent when specifically looked for by thin sectioning of tissue blocks and by special staining. Overall, hyphae were visualized in 55 percent, but they were rarely encountered in the same areas as spherules. A second report revealed hyphae in three of eight cavities and three of four granulomas. Hyphae were seen most frequendy on the surface of cavity walls and in necrotic debris within granulomas. Radiographic evidence of a fungus ball due to С immitis is also unusual, with only six previously published reports. This is usually defined as a mass within a cavity with a crescent of gas surrounding the mass and that is freely mobile with positional change. Both of these cases had radiographically documented fungus balls.
Previously there have been six well-documented case reports of the coexistence of hyphae with spherules in cavitary coccidioidomycosis published in the medical literature (Table 1). Three further cases of granulomas were also described by Fiese et al. No data referable to the individual were given in the report of Puckett. All patients had undergone limited pulmonary resection, usually due to hemoptysis. Only one patient had disseminated disease.
Chest radiographic data were included in four reports (chest radiograph or tomography) and documented the presence of fungus balls in all four. The present report underlines the utility of chest computed tomographic scanning or tomography in the documentation of the presence of a fungus ball.
All of the published reports have demonstrated the presence of hyphae and spherules from surgically removed specimens. To our knowledge, this is the first report of a pulmonary fungus ball diagnosed by fiberoptic bronchoscopic biopsy specimen. Although both patients described in this report presented with hemoptysis, at the time of initial presentation to Fitzsimons Army Medical Center, the first patient was symptomless with regard to her lung and had no evidence of hemoptysis; therefore surgery and amphotericin В therapy were withheld successfully. In the second case, cautious observation was utilized and resolution of hemoptysis and collapse of the cavity occurred. Although both patients had potential indications for surgery, both have continued to do well without any antifungal therapy or surgical excision of lesions to date, 18 and 29 months after their initial presentation. Although both patients have done well without surgical excision, close observation continues to be warranted; however, the potential complications and financial expense of surgical procedures* have been avoided in these patients thus far. In the absence of controlled information regarding the utility of azole antifungal agents, the potential side effects of amphotericin B, and the potential morbidity of surgical excision of cocci lesions, serious consideration should be given to cautious observation and/or nonsur-gical management of cavitary coccidioidomycosis.

Table 1—Demographics of Mixed Hyphae/Spherule Cavitary Coccidioidomycosis

Cases Source Age/Sex Race UnderiyingDisease Symptoms Diagnosis Serology Treatment Outcome Hyphae + Spherules
1 Rohatgi and Schmitt 61/M Filipino 1DDM Hemoptysis Sputumcultures 1:8 AMB, 2 g; lobectomy Good Yes
2 Ibadepalli et ah 26/M Black Disseminatedcocci Meningitis,slan,hemoptysis Skinculture 1:1,024 AMB, 4 g; lobectomy Good Yes
3 Feeetal 36/M Black None Hemoptysis Sputumculture 1:16 Lobectomy Good Yes
4 Putnam etal* 52/M White None Hemoptysis Sputumculture 1:8 Lobectomy;AMB TemporaryincreaseinCFtiter

1:256

Yes
5 Fiese etal* 24/M White None Chroniccough Sputumculture 1:64 Lobectomy Good Yes
6 Fiese etal* 39/M White None Hemoptysis, weight loss Sputumculture Negative Segmentalresection Good Yes
7 Fiese et al* 26/M White None Hemoptysisrecurrent Lung culture 1:256 Segmentalresection;lobectomy Good Yes
This entry was posted in Cavitary Coccidioidomycosis and tagged amphotericin, bronchoscopy, cavitary coccidioidomycosis, hemoptysis, hyphae spherules, lobectomy, skin test.