The Surgical Lesions of Pulmonary Cocoidioidomycosis

¹ Fitzsimons General Hospital, Denver, Colorado.

A total of ten cases are reported which have had surgery because of some complication of primary pulmonary coccidioidomycosis. Six of these cases had lobectomy and four had decortication.

Of the six lobectomies performed, four were done because of persistent symptoms associated with pulmonary cavitation. These cases had symptoms for fourteen, thirty-five, thirty-six and sixty-two months, respectively and had been hospitalized because of these symptoms for an average of twelve months. The chief complaint of all four patients was a feeling of weakness and ease of fatigue. All had a dry chronic cough and three had hemoptysis frequently, however, the hemoptyses were not serious in any case. Three were underweight and failed to gain weight during their hospitalization. Two had chronic low grade fever and two had chest pain of a pleuritic nature. With the exception of the chest pain, all symptoms were relieved promptly by surgery.

One lobectomy was performed on a patient with a large cavity in one lung field and a small round lesion in the opposite lung. The cavity measured from six to eight cm. in diameter and contained a fluid level. There was no change in either lesion after ten months of hospitalization and, although the patient had no symptoms, the cavity was removed by lobectomy. The lesion in the opposite lung remains unchanged.

The remaining lobectomy was performed because of an undiagnosed solid tumor of the left upper lobe. Following lobectomy the diagnosis of coccidioidoma was established.

The four decortications were performed because of nonexpansile lung following spontaneous pneumothorax. The diagnosis of coccidioidomycosis had been established in three of these cases prior to the collapse of the lung, and all three had pulmonary cavitation. At the time of surgery, each of these cases was demonstrated to have a bronchopleural fistula at the site of the cavitation. In the remaining case the cause of the spontaneous pneumothorax was not proven, but Coccidiodes immitis was isolated from the pleural fluid following the spontaneous collapse of the lung.

The surgery was performed without undue difficulty and there were no serious complications during the operations or immediately postoperatively. There was no evidence of dissemination of the disease following surgery in any of the cases. There was incomplete expansion of the lung following decortication in two cases; an apical thoracoplasty was performed on one of these patients and the other preferred to have no further surgery. Both cases are doing well. One patient developed hemoptysis three months following a right upper lobectomy performed because of cavitation with associated symptoms which had persisted over a period of three years. He was re-hospitalized and x-ray films revealed an infiltration and a small cavity within the apical portion of the remaining right lung. His sputum was strongly positive for acid-fast bacilli. Prior to surgery, tuberculin skin tests had been negative on first and second strengths and the sputum had been negative for acid-fast bacilli on twenty-one smears, ten cultures, and two guinea pig necropsies.

The mycelial form of Coccidioides immitis was identified within the cavities of four of the five cases having lobectomy for cavitation.