The Place of Excisional Surgery in the Treatment of Pulmonary Mycotic Infections

¹ The Veterans Administration Hospital.

From experience with 75 patients with pulmonary mycotic infections at Oteen, and from case reports of nearly 500 others in the literature, we have drawn the following conclusions:

1. North American blastomycosis is currently best treated by 2-hydroxystilbamidine, in spite of a relapse rate of approximately 25 per cent. Excision of cavities should be undertaken only after adequate chemotherapy. The surgical mortality rate without drug coverage is 24 per cent, half of it due to dissemination of disease.

2. Excision of coccidioidomycotic cavities should be done if they are very large, secondarily infected, productive of repeated hemorrhages, or have ruptured into the pleural space. Asymptomatic or mildly symptomatic small cavities should probably be left alone. These rarely cause significant symptoms, whereas excision is followed by an appreciable morbidity (13 per cent) and mortality (2 per cent).

3. The need for excision of chronic cavities of histoplasmosis has not been clearly determined. In the absence of specific drug therapy it seems rational to recommend excision of localized destructive lesions. The mortality rate following excision is 16 per cent.

4. Focal granulomas due to coccidioidomycosis or histoplasmosis need not be resected therapeutically. Since they usually cannot be differentiated from other "coin lesions," resection for diagnosis will often continue to be necessary. This can be done with relative safety.