Infection with the dimorphic fungus, Coccidioides immitis, is common in the southwestern United States and other areas of the lower Sonoran life zone. Inhalation of arthrospores results in pulmonary infection that is usually symptomless and recognized only by skin test conversion. A pneumonia, clinically apparent or not, may resolve completely or persist, and sequelae of the infection may be seen roentgenologically as a nodule or cavity. Rarely, a solid nodule can excavate and present as a fungus ball radiographically. canadian neighbor pharmacy
The best diagnostic and therapeutic management of pulmonary cavitary coccidioidomycosis is uncertain. Surgical complications in the past have been considerable and recommendations for perioperative use of amphotericin В have been advocated. Some surgical approaches have emphasized lobectomy as a minimum. Others have reported favorable surgical outcomes with more limited resection (segmental or wedge) and without using amphotericin B. The presence of diabetes is thought to mandate more aggressive surgery. Although the natural history of untreated cavitary coccidioidomycosis may result in spontaneous pneumothorax with empyema, the relative risk appears small, and close observation without surgery may be warranted.
The role of azole therapy for cavitary coccidioidomycosis is unknown. Percutaneous needle biopsy has been useful in distinguishing Coccidioides nodules from malignancy but the rate of pneumothorax may be unacceptably high. Fiberoptic bronchoscopy has been successfully used to elucidate the origin of Coccidioides lesions, primarily through culture of secretions.
We describe two patients with fungus ball formation secondary to cavitary coccidioidomycosis, one of whom was found to have coexistent spherules and hyphae on histologic analysis of bronchoscopic biopsy specimen. No specific antifungal therapy or surgical excision was utilized and both patients have done well for 18 and 29 months, respectively. To our knowledge, this is the first documentation of spherules and hyphae discovered in other than a surgical specimen.