Ann Thorac Surg 2002;74:926-927
© 2002 The Society of Thoracic Surgeons
Case report
Scopulariopsis fungus ball
Shunsuke Endo, MD*a,
Mitsugu Hironaka, MDa,b,
Fumio Murayama, MDa,b,
Tsutomu Yamaguchi, MDa,b,
Yasunori Sohara, MDa,b,
Ken Saito, MDa,b
a Department of Thoracic Surgery, Jichi Medical School, Tochigi, Japan
b Department of Pathology, Jichi Medical School, Tochigi, Japan
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Endo, Department of Thoracic Surgery, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi 329-0498, Japan
e-mail: tcvshun{at}jichi.ac.jp
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Abstract
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We report on a 67-year-old woman with a rare Scopulariopsis fungus ball in the right middle lung lobe. Pathologic examinations after right middle lobectomy showed that the lesion contained a moniliaceous mold fungus that was cultured and identified as Scopulariopsis. The patient’s postsurgery course was uneventful.
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Introduction
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Scopulariopsis is a saprophytic fungus found in the soil and in plant stems and juices [1]. Scopulariopsis is isolated most often in association with otomycosis or onychomycosis, but it has been isolated occasionally in association with lung conditions in immunocompromised patients and drug addicts [1, 2]. The case we report here was atypical in that the Scopulariopsis infection appeared to be a superinfection but our patient did not match the profile of other reported patients. We account for our findings and discuss treatment.
A 67-year-old woman who had been treated for 1 year for a fungus ball observed radiographically in the right middle lung lobe was referred to us. The lesion, situated in a lateral lung segment, was 3 cm in diameter, and the meniscus sign was present on a chest computed tomographic scan (Fig 1).
Blood cell counts and serum chemistry values were normal. Erythrocyte sedimentation was slightly increased to 30 mm/hour. Tests for antibody against Aspergillus were negative. Arterial blood gas values on room air and respiratory function were normal.
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Fig 1. Chest computed tomographic scan showing a fungus ball within a cavity in the right middle lung lobe.
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A right middle lobectomy was performed via lateral thoracotomy. A section of the middle lobe showed brown material situated within a 4 x 2 x 3 cm fibrous-wall cavity. Hematoxylin and eosin staining of cavity wall sections revealed dilated bronchioles that were composed of fibrous tissue containing varying numbers of lymphoplasmacytes. The friable material was a conglomeration of intertwined fungal hyphae admixed with a few neutrophils. Tissue invasion of the organism was not observed. Gomori methenamine silver staining showed thin, septate hyphae with dichotomous branching (Fig 2).
Scopulariopsis was identified by culture. Antifungal therapy with fluconazole was begun and continued postoperatively for 1 month. The patient’s postoperative course was uneventful and she was discharged 3 weeks after surgery.
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Fig 2. High-power photomicrograph (x400) of section stained with Gomori methenamine silver depicts hyphae that are thin, and septate. Dichotomous branching is seen. Fungus was identified by culture as Scopulariopsis.
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Comment
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Scopulariopsis fungi were first described in 1907. On histologic tissue sections, they appear virtually identical to the more common Aspergillus species and very similar to Penicillium species. Scopula means "broom" in Greek, and the primary feature of Scopulariopsis is its broom-shaped conidiophores seen only in culture; thus, definite identification is obtained only by culture [3].
Cultures from nail scrapings often yield the fungus. Scopulariopsis can cause some superficial infections such as otomycosis and onychomycosis. Scopulariopsis species accounted for 451 (1%) fungal isolates recovered from the respiratory tract of patients at the Mayo Clinic between 1975 and 1980 [4]. Some invasive Scopulariopsis infections starting from the ear, nose, toe, lung, or brain have been reported in immunocompromised patients and drug addicts [3–5]. Hypersensitivity pneumonitis and pneumonia due to Scopulariopsis infection have occurred [1, 2]. To our knowledge, this opportunistic fungus has been reported only once in association with a pulmonary fungus ball [5], but it remains unclear whether this was indeed a rare occurrence of Scopulariopsis, since identification is made only by culture. The pathologic study showed that Scopulariopsis superinfected the dilated bronchiole. The bronchiole may be impaired under conditions of chronic infection.
Treatment with antifungal agents and antibiotics may be limited, as Scopulariopsis is often resistant to antifungal agents including amphotericin B [3, 6]. Therefore, surgical resection of the cavity is essential when the local immunosystem is compromised, even though the fungus is identified preoperatively.
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References
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- Grieble H.G., Rippon J.W., Maliwan N., et al. Scopulariopsis and hypersensitivity pneumonitis in an addict. Ann Intern Med 1975;83:326-329.
- Wheat L.J., Bartlett M., Ciccarelli M., et al. Opportunistic scopulariopsis pneumonia in an immunocompromised host. South Med J 1984;77:1608-1609.[Medline]
- Ellison M.D., Hung R.T., Harris K., et al. Report of the first case of invasive fungal sinusitis caused by scopulariopsis acremonium: review of scopulariopsis infections. Arch Otolaryngol Head Neck Surg 1998;124:1014-1016.[Abstract/Free Full Text]
- Phillips P., Wood W.S., Phillips G., et al. Invasive hyalohyphomycosis caused by scopularopsis brevicaulis in a patient undergoing allogenic bone marrow transplant. Diagn Microbiol Infect Dis 1989;12:429-432.[Medline]
- Larsh H.W. Opportunistic fungi in chronic disease other than cancer and related problems. In: Iwata K., ed. Recent advances in medical and veterinary mycology. Baltimore: University Park Press, 1977:221-229.
- Neglia J.P., Hurd D.D., Ferrieri P., et al. Invasive scopulariopsis in the immunocompromised host. Am J Med 1987;83:1163-1166.[Medline]
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Abstract
Introduction
