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Ann Thorac Surg 2009;88:1765-1772. doi:10.1016/j.athoracsur.2009.07.075
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Surgery for Pulmonary Coccidioidomycosis: A 10-Year Experience

Dawn E. Jaroszewski, MDa,*, Wissam J. Halabi, MDa, Janis E. Blair, MDb, Brandon J. Coakley, BSb, Raymond K. Wong, PhD, CCPa, James M. Parish, MDc, Laszlo T. Vaszar, MDc, Shimon Kusne, MDb, Holenarasipur R. Vikram, MDb, Paterick A. DeValeria, MDa, Louis A. Lanza, MDa, Francisco A. Arabia, MDa

a Division of Cardiovascular and Thoracic Surgery, Mayo Clinic, Scottsdale, Arizona
b Division of Infectious Diseases, Mayo Clinic, Scottsdale, Arizona
c Division of Pulmonary Medicine, Mayo Clinic, Scottsdale, Arizona

Accepted for publication July 28, 2009.

* Address correspondence to Dr Jaroszewski, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85043 (Email: jaroszewski.dawn{at}mayo.edu).

Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Coccidioidomycosis results from infection with Coccidioides species endemic to the southwestern United States. The mobile US population has resulted in incremental cases being found throughout the world. The fungal infection can result in pulmonary sequelae, including nodules, cavities, and complications requiring treatment by the thoracic surgeon.

Methods: A retrospective chart review was conducted of 1,496 patients with coccidioidomycosis treated at our institution (January 1998 to December 2008) to identify those requiring surgery.

Results: Of the 1,496 patients, 86 (6%; mean age, 58 years [range, 18 to 81], 48 women) underwent operations. Radiographs revealed 59 nodules, 18 cavities, 2 infiltrates, and 7 complications of disease (e.g., effusion, pneumothorax, and empyema). Of the 86 patients, 40% underwent resection for persistent symptoms or disease progression despite adequate antifungal therapy. One third of the operations were performed by video-assisted thoracoscopic surgery. Morbidity, 21% (18 patients), and in-hospital mortality, 2% (2 patients), were greater after resection for cavitary lesions with resultant complications versus for nodular disease: 41% versus 12% (p ≤ 0.002) and 8% versus 0% (p < 0.005). Prolonged air leaks or bronchopleural fistulas were the most common complications (13 patients). Postoperative antifungal therapy was administered to 42% of patients (89% of cavitary and complicated). There were no cases of recurrence at follow-up (mean, 24 months).

Conclusions: Surgical intervention was indicated for only a few patients, most commonly for diagnostic dilemmas involving nodular disease, symptomatic nonresponsive cavitary disease, or complications. Prolonged air leaks were the main cause of morbidity. Resection should result in symptom resolution and long-term freedom from recurrence.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Coccidioidomycosis is a fungal infection caused by inhalation of the spores of the soil-dwelling fungus Coccidioides species endemic to the southwestern United States [1–4]. Coccidioidomycosis is found in geographic regions where the climate is hot and dry and the alkaline soil provides optimal growth conditions for the dimorphic fungus [3–8]. There has been an explosive increase in the number of patients identified with coccidioidal infection in endemic areas, due in part to an influx of susceptible hosts as part-time or full-time residents or as visitors [4, 5]. Often called "valley fever," coccidioidomycosis affects an estimated 150,000 persons annually [2, 4, 5]. The high mobility of the US population also results in a substantial number of cases occurring outside endemic areas, which often presents a diagnostic challenge. Because some patients with coccidioidal infection have pulmonary complications, the thoracic surgeon should be knowledgeable about the disease and how to approach it.

Symptomatic coccidioidal infection is usually manifested as a flulike illness, and it is a common cause of community-acquired pneumonia in endemic areas [2, 3]. Symptoms usually include cough, fatigue, chest pain, fever, hemoptysis, weight loss, dyspnea, malaise, night sweats, and chills [2–4, 9]. On chest radiographs and computed tomography scans, the infection may appear as patchy unilateral or bilateral infiltrates or as an area of consolidation. The infiltrates can be associated with hilar adenopathy and may extend across the fissure as bilobar disease. Approximately 5% to 10% of coccidioidal infections result in residual pulmonary sequelae such as nodules and cavities (Figs 1 and 2) [1, 2]. Immunosuppressed patients and patients with diabetes mellitus are particularly susceptible to severe coccidioidal infection and its resulting complications, including pneumonia and chronic or relapsing illness [1–4].


Figure 1
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  		Fig 1. Computed tomogram (arrow) shows a pulmonary coccidioidal cavitary lesion with effusion in an 18-year-old woman who presented with cough, fever, and shortness of breath.

 

Figure 2
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  		Fig 2. Computed tomogram (arrow) shows a nodular coccidioidal lesion adherent to the pleura in a 47-year-old woman who presented with cough, fatigue, and chest pain.

 
Most coccidioidal infections are self-limited and resolve with or without antifungal treatment [3, 5, 8]. However, a small percentage of patients require surgery as definitive or adjunct treatment. Patients with residual nodules or cavitations, of concern because of the possibility they might be neoplasms, are often referred to the surgeon for further management. Cavitary coccidioidomycosis may be asymptomatic or associated with chronic cough, hemoptysis, systemic symptoms, rupture, and pneumothorax or hemothorax, bronchopleural fistulae, and secondary infections requiring surgical intervention [4, 10–30].

Coccidioidomycosis is identified more frequently in the southwestern United States, which has had an increase in visitors from across the country and around the world. Thus, we sought to conduct a review of all patients with pulmonary coccidioidomycosis who were treated at our institution between January 1998 and December 2008. Our aims were to determine the incidence of surgical interventions in a population of patients with a diagnosis of coccidioidomycosis and to determine the types and outcomes of the surgical interventions performed. Our hope is that this information will aid clinicians and thoracic surgeons who must treat patients with coccidioidomycosis.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Study Design
A retrospective review of the institutional database of medical records was conducted to identify all consecutively evaluated patients with documented coccidioidal infection who were treated at Mayo Clinic, Scottsdale, Arizona, during the 10-year period between January 1998 and December 2008. The Institutional Review Board approved the study and waived patient consent on the condition that patient data are de-identified. Patients with coccidioidal infections treated at our institution were identified by reviewing all cases of coccidioidomycosis reported to the Arizona Department of Health Services by our institution. These reports were compiled on the basis of microbiological cultures of any source of Coccidioides sp, positive pathologic results (demonstrating spherules) or positive serologic results. The charts of such patients were retrospectively reviewed and the following information was abstracted: site of the coccidioidal infection (lung versus extrapulmonary site), characteristics of the first radiographic findings (ie, infiltrate, nodule, cavity, empyema, pneumothorax, or effusion), and type of treatment. For patients who underwent surgery, extended chart abstraction included clinical and radiographic indications for surgery, diagnostic methods, surgical procedure, postoperative complications, antifungal therapy preoperatively and postoperatively, and follow-up. Depending on the location and extent of the lesions, the operations were carried out in a routine fashion similar to that of other pulmonary resections (ie, pneumonectomy, lobectomy, or segmental or wedge resection). Complications were reported in accordance with the definitions established by The Society of Thoracic Surgeons.

Statistical Methods
For analysis, dichotomous or categorical variables were summarized as numbers and percentages. Differences in distributions of dichotomous variables were analyzed by using the Fisher exact test when appropriate. Continuous variables were summarized as means and ranges.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Patients
Between January 1998 and December 2008, 1,496 patients were given a diagnosis of coccidioidomycosis (Table 1). Of these patients, 86 (6%) underwent surgical procedures. The mean age of the surgical patients was 58 years (range, 18 to 81). Forty-eight (56%) were women and 38 (44%) were men. Immunosuppression due to an autoimmune disorder or transplantation (12%) or due to diabetes mellitus (12%) was present in one fourth of the patients who required surgery. Thirty-eight (44%) of the 86 patients had a history of tobacco abuse and 34 (40%) had a current or previous diagnosis of cancer.


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  		Table 1 Sites of Involvement and Indications for Surgery in 1,496 Patients With Coccidioidomycosis (January 1998 to December 2008)
 
Patients were categorized by their radiographic findings at presentation for surgical consultation. Fifty-nine (69%) of the 86 patients had nodular disease, 18 (21%) had cavitary disease, 2 (2%) had infiltrative disease, and 7 (8%) had complications of cavitary disease that included effusion, pneumothorax, and empyema.

Indications for surgery were diagnosis (58 patients), failure of disease to respond to antifungal treatment (10 patients), unrelenting symptoms alone (11 patients), or complications related to coccidioidomycosis (7 patients). Twenty-nine patients (34%) had coccidioidal symptoms at the time of surgery. Eleven patients (13%) underwent surgery only because their symptoms were refractory to antifungal therapy. Both of the patients with infiltrative disease who underwent excisional biopsy had symptoms, as did all of the patients with complications related to the rupture of their cavitary disease. Patients with uncomplicated cavitary disease were more likely to have symptoms (14 of 18 [78%]) versus patients with nodular disease (6 of 59 [10%]). Surgery resulted in the resolution of symptoms in 28 of the 29 symptomatic patients. One patient with cavitary disease continued to have symptoms of malaise and fatigue despite resection. Table 2 summarizes the prevalent signs and symptoms of the 86 patients who had surgery.


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  		Table 2 Signs and Symptoms of Coccidioidomycosis in 86 Surgical Candidates
 
Preoperative Antifungal Therapy
Only 37 (32%) of the 86 patients had preoperative antifungal therapy, with treatment lasting 1 week to 3 years before surgical resection. The most common antifungal agents utilized were fluconazole (64%) and amphotericin B (21%). Posaconazole, itraconazole, and vorconizole were also used in a few patients whose disease was not responsive to current treatment or whose side effects were intolerable. Treatment choices were based on physician preference, patient tolerance profile, and insurance allowances, as well as on any documented antifungal resistance. No conclusions could be drawn about the optimal length of antifungal therapy on the basis of disease advancement or progression to complications.

Patients With Nodular Radiographic Findings
Fifty-eight (67%) of the 86 patients underwent surgery for diagnostic purposes only. Fifty-three (91%) of these 58 patients had radiographic findings of nodules with a differential diagnosis of cancer. Thirty-four patients in the nodule category had a previous or current diagnosis of cancer: lung cancer (8 patients); adenocarcinoma of the colon, esophageal, prostate, or other site (10 patients); sarcoma or other stromal-based tumors (5 patients); carcinoid (4 patients); melanoma (4 patients); and lymphoma (3 patients). Incidental cancer was found in 17 patients at the time of the surgical procedure for coccidioidomycosis. Nineteen patients had positron emission tomography with uptake in the nodules highly suspicious for malignancy, and 6 patients had undergone attempted percutaneous, transthoracic computed tomography–guided biopsies that were nondiagnostic. Coccidioidal serology was negative for 13 (62%) of the 21 patients with nodular disease in whom serologic testing was performed.

Patients With Cavitary Lesions
Residual cavities that failed to resolve or presented diagnostic concerns were therapeutically removed in 18 (21%) of the 86 patients who underwent surgery. Symptoms were present in 14 (78%) of these 18 patients. Ten patients had cavities that were unresponsive to long-term antifungal therapy or were increasing in size despite such treatment. Antifungal therapy was given preoperatively for 1 month to 7 years. Many patients had lapses in treatment and changes in antifungal therapy. The lack of consistency in antifungal treatment precluded definitive conclusions about the optimal medical therapy. Spherules of Coccidioides sp were identified by histologic testing in the resected specimens in all cases. Seventeen of these 18 patients had coccidioidal serologic testing performed, and results were positive in 14 (82%) of the 17.

Patients With Infiltrative Disease on Radiographs
Two patients with increasing infiltrates underwent resection for diagnosis. One of these patients had chronic lymphocytic lymphoma, and no previous antifungal therapy had been initiated because coccidioidal serology had been negative. The other patient had positive serology and worsening of infiltrates despite 3 months of antifungal treatment with fluconazole followed by an additional 3 months of treatment with amphotericin B.

Patients With Complications Due to Coccidioidal Rupture
Seven patients presented with complications related to pulmonary coccidioidomycosis. Empyema or effusion from cavity rupture occurred in 4 patients, and spontaneous pneumothorax occurred in 3 patients.

Procedures
Of the 86 patients who had surgery, 29 (34%) underwent resection with video-assisted thoracoscopic surgery (VATS). The types and numbers of surgical procedures are summarized in Table 3. In 3 patients, median sternotomy was being performed for other purposes, such as valve replacement (2 patients) or coronary artery bypass graft surgery (1 patient). One patient who was deemed too medically unstable to undergo further surgery underwent an Eloesser flap for treatment of empyema caused by a ruptured cavity and necrotic lung. Intraoperative findings included excessive adhesions and thickened pleura (38%), fibrosis and scarring of the affected lobe down to the bronchus (28%), and multiple satellite lesions (12%). Cavitary lesions were often accompanied by dense adhesions that required a formal thoracotomy rather than VATS for resection (only 2 of the 18 patients with cavitary lesions had resection by VATS). In 8 patients, VATS required conversion to open cases because of excessive adhesions, fibrosis, or numerous satellite lesions. Two patients required extrapleural dissections because of complete adhesion of the lung to the pleura. Ten patients had multiple satellite lesions of coccidioidomycosis throughout the lobe; in 9 of these 10, a lobectomy was necessary to remove all diseased tissue. Two patients had extensive disease in both lobes with massive scarring that required pneumonectomy.


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  		Table 3 Type of Surgical Procedure by Type of Radiographically Documented Abnormality in 86 Patients With Coccidioidomycosis
 
Morbidity and Mortality
Eighteen of the 86 patients experienced postoperative complications. The most common complications were prolonged air leaks lasting longer than 5 days (10 patients [56%]) and bronchopleural fistulas (3 patients [17%]). Four patients who had air leaks that persisted for 12 to 25 days were discharged home with a Heimlich valve; their leaks resolved within 1 to 2 weeks. Table 4 summarizes the types of disease identified by radiographs, the procedures performed, and any complications. The probability of postoperative complications was more frequent in patients who had cavitary lesions or complicated cavitary lesions than in patients who had nodules (7 patients [41%] versus 11 patients [12%]; p < 0.002). Patients with complications were more likely to have been treated with preoperative antifungal therapy for an extended period but this finding was not significant. The average hospitalization for all patients was 7 days (range, 2 to 67).


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  		Table 4 Morbidity and Mortality in 18 Patients With Coccidioidomycosis by Type of Surgical Procedure
 
Three patients died after surgery. In-hospital mortality was 2% (2 patients; 1 on postoperative day 47 and 1 on postoperative day 67). One patient died at home 1 week after an uncomplicated postoperative course and discharge from the hospital. Both patients who died in the hospital had extensive and complicated cavitary disease. One of these 2 patients, a 71-year-old woman, had a large bilobar lesion that required an extrapleural pneumonectomy. Bronchopleural fistula, bacterial sepsis, and acute respiratory distress syndrome developed and the patient died on postoperative day 67. The second patient was a 74-year-old woman with diabetes mellitus and steroid-dependent rheumatoid arthritis. She presented initially to the hospital with a ruptured cavity and empyema. Despite surgical decortication and drainage, her condition continued to decline; sepsis, acute respiratory distress syndrome, and intestinal ischemia developed, and the patient died on postoperative day 47.

Postoperative Antifungal Therapy
At the discretion of the referring physician, nearly half (42%) of the patients were maintained postoperatively on antifungal therapy. Fifteen (83%) of the 18 patients with uncomplicated cavitary and 12 (20%) of the 59 patients with nodular disease received postoperative antifungal therapy. All patients with ruptured cavitary disease, including pneumothorax and empyema, received postoperative antifungal therapy. The duration of antifungal treatment was 3 months for most patients but ranged from 1 month to 2 years, depending on continued positive findings of coccidioidal serology. The most common antifungal therapy was fluconazole, which was administered to 83% of the patients who received antifungal therapy. For patients who were intolerant to fluconazole or who had an insufficient response with it, other antifungal treatments were used: amphotericin B (3 patients), voriconazole (2 patients), itraconazole (2 patients), and posaconazole (1 patient).

Follow-Up
Patients had a mean follow-up of 24 months (range, 30 days to 9 years). No patient experienced recurrent pulmonary coccidioidomycosis. One patient had continued symptoms and positive serology despite antifungal treatment for 2 years. One patient required readmission and open decortication for bacterial empyema that developed 3 weeks after VATS for wedge resection of a ruptured cavity and spontaneous pneumothorax.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Many patients with pulmonary coccidioidomycosis experience resolution of this fungal infection without treatment or administration of antifungal therapy. However, numerous patients with coccidioidal illness that fails to resolve and is accompanied by complications may ultimately be placed in the care of the surgeon. These patients can also present as a diagnostic dilemma. As the number of cases of coccidioidomycosis continues to rise, so too does the need for knowledgeable thoracic surgeons who have an understanding of this infection. No new surgical literature on adult patients with pulmonary coccidioidomycosis has been published since 1980 [10–29]. These early reports noted high rates of complications, intermittent use of antifungal therapy, and frequent recurrences.

Our surgical approach to the treatment of patients with coccidioidomycosis has changed during the past 10 years. Specifically, in more recent years, VATS has increasingly been used, reflecting an increase in the experience and comfort level of surgeons in performing more complex VATS procedures. Between 1998 and 2004, only 10 (22%) of 44 resections were performed using VATS, whereas between 2005 and 2008, 19 (45%) of 42 surgical procedures used VATS (Table 5). The mean ± SD length of hospital stay was significantly shorter in patients who had VATS versus open surgery (3.85 ± 3.9 versus 8.2 ± 9.6 days; p < 0.05). Video-assisted thoracoscopic surgery was used most commonly in diagnostic cases for the removal of nodules. Considerable scarring, adhesions, and fibrosis were common in patients with persistent cavitary lesions. Video-assisted thoracoscopic surgery was used whenever possible; however, open thoracotomy was required in 89% of patients because of the complicated nature of the thoracic space.


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  		Table 5 Resections With Video-Assisted Thoracoscopic Surgery (VATS) Versus Open Surgery (January 1998 to December 2008)a
 
Patients with coccidioidomycosis often present to the surgeon with two separate disease entities. Nodules rarely advance to complications or symptoms but remain a diagnostic challenge. In contrast, cavitary coccidioidomycosis can become a much more severe and potentially complicated disease, and the timing of operative intervention is controversial. For discussion purposes, we have divided these two presentations into diagnostic surgical procedures for indeterminate pulmonary findings, and therapeutic surgical procedures for persistent refractory coccidioidomycosis or complications of coccidioidal illness.

Diagnostic Surgical Procedures for Indeterminate Pulmonary Findings
Despite advances in imaging and technology, patients with coccidioidal lung nodules may present a diagnostic dilemma because neoplasms must be excluded [30]. Surgery is recommended for patients who are medically able to withstand it and in whom suspicion of cancer is warranted because of the possibility of otherwise missing a potential cancer and because of the ease with which a VATS biopsy specimen can be obtained.

Interventional needle biopsy can be considered for many nodules, but it often has a relatively poor positive diagnostic yield with coccidioidomycosis (8.6% yield [31]; 29% indeterminant findings [32]). Percutaneous biopsy can also be complicated by the risk of dissemination of disease by the procedure [31, 32] and by the potential for bronchopleural fistulas, such as occurred in 1 of our patients. The usefulness of serologic studies is limited as well. A large percentage of residents in any endemic area will have negative serologic results even with pathologic confirmation of pulmonary infection, especially in cases of nodular disease. In our series of 59 patients with nodules, serologic tests were particularly unreliable, with 62% of patients having negative results. Other imaging methods, such as positron emission tomography and computed tomography scans, are often not useful in the differential diagnosis because the residual metabolic activity of coccidioidal lesions has enough uptake to leave doubt. In geographic regions with an increased prevalence of pulmonary fungal infections, positron emission tomography is sensitive but has low specificity and negative predictive value [30, 33]. One review of 200 solitary pulmonary nodules undergoing resection in Arizona found most to be coccidioidal, but 35% were malignant [34]. In our own population, nodules that were excised for diagnostic purposes were associated with a concurrent or previous cancer diagnosis in 40% of patients. In 17 patients, cancer was found in addition to a coccidioidal nodule during the excisional procedure.

Surgery as Treatment for Persistent Refractory Coccidioidomycosis
Most asymptomatic stable cavities causes by coccidioidomycosis eventually close without surgical intervention. Patients should undergo surgical resection if they experience continued symptoms, lack of resolution, or growth in cavitary disease despite adequate antifungal treatment (Fig 3). The proper timing of referral to a thoracic surgeon is unknown. When cavities continue to enlarge or the patient does not experience clinical resolution of symptoms with first-line or second-line triazole antifungal agents, a reassessment by an infectious diseases specialist is necessary and consultation with a thoracic surgeon should be considered so that the patient can discuss the risks, benefits, and potential complications of resection. Patients with immunosuppression, diabetes mellitus, or other clinically significant medical conditions should be referred sooner because complications from advanced disease can prolong postoperative recovery or even result in death. The overall goal for any patient should be resection before the disease becomes complicated.


Figure 3
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  		Fig 3. Coccidioidomycosis treatment algorithm. (VATS = video-assisted thoracoscopic surgery.)

 
The complications of coccidioidal cavities can parallel those of lung abscess or bronchiectasis, including ruptured cavity with pleural effusion, pneumothorax, empyema, and bronchopleural fistulae. Four (57%) of the 7 patients who presented with rupture of their coccidioidal cavity experienced clinically significant complications after operative treatment, and 1 patient with immunosuppression died after contracting sepsis. Delay in surgical treatment with concomitant worsening of disease may also complicate the surgical field and contribute to postoperative complications. Prolonged air leaks and bronchopleural fistulas were the most common types of morbidity experienced after resection of extensive cavitary disease (Table 4). Most of the complications appeared to be a consequence of the inflammatory nature of the coccidioidal infection and the extent of resection required to clear all diseased tissue. Cavitary disease requiring full lobectomy or pneumonectomy was severe, with reactive fibrosis apparent even down to the bronchial stump. Lobectomy for resection was associated with prolonged air leaks in 7 (39%) of the 18 patients who had surgery for extensive cavitary disease. Bronchopleural fistula occurred in the patient who required pneumonectomy. No patient who underwent a simple wedge resection of cavitary disease without associated complications of empyema, pneumothorax, or effusion experienced any postoperative morbidity.

Postoperative Antifungal Therapy
Azoles are currently the preferred agents for the treatment of most forms of coccidioidomycosis [8, 35]. There are vast differences in the efficacy of the different azoles, in the tolerance of patients to them, and in the extent of clinical experience with them [5, 8, 35, 36]. Thus, consultation with an infectious diseases specialist is critical for postoperative antifungal treatment and follow-up of these patients. Patients who have large nodular lesions, clinically significant cavitary disease, or multiple satellite lesions with active coccidioidal infection on histologic evaluation should be administered postoperative antifungal therapy for at least 2 to 3 months. Complicated disease, especially rupture of the cavity with contamination of the pleural space, should be treated with antifungal treatment for at least 3 to 6 months. Patients in our series who had positive serologic results received antifungal treatment for at least 3 months. Follow-up serologic tests were monitored, and decisions about ongoing therapy and optimal treatment length were based on these results. There was no recurrence of pulmonary disease in our series at a mean follow-up of 2 years.

In conclusion, patients with coccidioidomycosis are presenting more frequently to the thoracic surgeon because of an enlargement of endemic zones and the increased exposure of our mobile population to these geographic areas. The most common presentations are nodules and cavities. Nodules rarely advance to complications or symptoms but remain a diagnostic challenge because of the possibility that they are carcinoma. Cavitary coccidioidomycosis can become a much more severe and potentially complicated disease. As surgical procedures become less invasive with shorter hospitalizations and reduced morbidity, patients with coccidioidal lesions may benefit from earlier surgical intervention. The goal of the thoracic surgeon should be to intervene before the disease progresses and complications occur. Patients should undergo surgical treatment if they experience continued symptoms, lack of resolution of the coccidioidal infection, or growth in cavitary disease despite adequate antifungal treatment. Long-term freedom from disease recurrence and the resolution of symptoms can be expected with surgical resection of pulmonary coccidioidomycosis.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
The authors acknowledge Qing Wu, ScD, for biostatistical analysis provided.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Chiller TM, Galgiani JN, Stevens DA. Coccidioidomycosis Infect Dis Clin North Am 2003;17:41-57.[Medline]
  2. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis Clin Infect Dis 2005;41:1217-1223.[Free Full Text]
  3. Saubolle MA, McKellar PP, Sussland D. Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis J Clin Microbiol 2007;45:26-30.[Free Full Text]
  4. Crum NF, Lederman ER, Stafford CM, et al. Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine 2004;83(3):149-175.[Medline]
  5. Anstead GM, Graybill JR. Coccidioidomycosis Infect Dis Clin North Am 2006;20:621-643.[Medline]
  6. Batra P, Batra RS. Thoracic coccidioidomycosis Semin Roentgenol 1996;31:28-44.[Medline]
  7. Galgiani JN. Coccidioidomycosis West J Med 1993:153-171.
  8. Galgiani JN, Ampel NM, Catanzaro A, Johnson RH, Stevens DA, Williams PL. Practice guideline for the treatment of coccidioidomycosis. Infectious Diseases Society of America. Clin Infect Dis 2000;30:658-661.[Free Full Text]
  9. Bowers JM, Mourani JP, Ampel NM. Fatigue in coccidioidomycosis. Quantification and correlation with clinical, immunological, and nutritional factors. Med Mycol 2006;44:585-590.[Medline]
  10. Winn WA. A long term study of 300 patients with cavitary-abscess lesions of the lung of coccidioidal origin. An analytical study with special reference to treatment. Dis Chest 1968;54(Suppl 1):268.[Medline]
  11. Cunningham RT, Einstein H. Coccidioidal pulmonary cavities with rupture J Thorac Cardiovasc Surg 1982;84:172-177.[Abstract]
  12. Melick DW. Surgical treatment of pulmonary coccidioidomycosis Arizona Med 1949;6:24-25.
  13. Connelly MB, Zerella JT. Surgical management of coccidioidomycosis in children J Ped Surg 2000;35:1633-1634.[Medline]
  14. Grant AR, Melick DW. The surgical treatment of cavitary pulmonary coccidioidomycosis Arch Surg 1967;94:559-566.[Abstract/Free Full Text]
  15. Rivkin LM, Winn DF, Salyer JM. The surgical treatment of pulmonary coccidioidomycosis J Thorac Cardiovasc Surg 1961;42:402-412.[Medline]
  16. Williams GD, Flanigan WJ, Campbell GS. Surgical management of localized thoracic infections in immunosuppressed patients Ann Thorac Surg 1971;12:471-482.[Abstract/Free Full Text]
  17. Nelson AR. The surgical treatment of pulmonary coccidioidomycosis Curr Probl Surg 1974:1-48.
  18. Aronstam EM, Hopeman AR. Surgical experiences with pulmonary coccidioidomycosis. A survey of 112 operative cases. J Thorac Cardiovasc Surg 1961;42:200-205.[Medline]
  19. Cogswell HD. The surgical aspects of coccidioidomycosis West J Surg Obstet Gynecol 1955;63:470-472.[Medline]
  20. Cotton BH, Paulsen GA, Birsner JW. Surgical considerations in pulmonary coccidioidomycosis: report of 100 cases Am J Surg 1955;90:101-106.[Medline]
  21. Fosburg RG, Baisch BF, Trummer MJ. Limited pulmonary resection for coccidioidomycosis Ann Thorac Surg 1969;7:420-427.[Free Full Text]
  22. Greer SJ, Forsee JH, Mahon HW. The surgical management of pulmonary coccidioidomycosis in focalized lesions J Thorac Surg 1949;18:591-604.[Medline]
  23. Guadalajara J, Costilla A, Chapa R, Chavez A, Anzaldua S. Pulmonary resection as treatment for coccidioidomycosis of the lung. Review of 40 cases. Int Surg 1969;52:273-276.[Medline]
  24. Guilfoil PH. Surgical therapy for pulmonary coccidioidomycosis Am J Surg 1953;19:975-980.
  25. Johnson PC, Sarosi GA. The endemic mycoses: surgical considerations Semin Thorac Cardiovasc Surg 1995;7:95-103.[Medline]
  26. Melick DW. Surgical treatment of pulmonary coccidioidomycosis: local excision of small lesions Arizona Med 1949;6:24.
  27. Salomon NW, Osborne R, Copeland JG. Surgical manifestations and results of treatment of pulmonary coccidioidomycosis Ann Thorac Surg 1980;30:433-438.[Abstract/Free Full Text]
  28. Spebar MJ, Jarstfer BS, Zeigler MG. Operative management of chronic coccidioidomycosis Am J Surg 1977;134:777-779.[Medline]
  29. Timmes JJ, Baum GL. Surgery in pulmonary coccidioidomycosis Dis Chest 1957;31:308-315.[Medline]
  30. Croft DR, Trapp J, Kernstine K, et al. FDG-PET imaging and the diagnosis in a region of high histoplasmosis prevalence Lung Cancer 2002;36:297-301.[Medline]
  31. Mitruka S, Landreaneau RJ, Mack MJ, et al. Diagnosing the indeterminate pulmonary nodule: percutaneous biopsy versus thoracoscopy Surgery 1995;118:676-684.[Medline]
  32. Forseth J, Rohwedder JJ, Levine BE, Saubolle MA. Experience with needle biopsy for coccidioidal lung nodules Arch Intern Med 1986;146:319-320.[Abstract/Free Full Text]
  33. Nguyen BD. F-18 FDG PET/CT imaging of disseminated coccidioidomycosis Clin Nuclear Med 2006;31:568-571.[Medline]
  34. Read CT. Coin lesion, pulmonary: in the Southwest. (Solitary pulmonary nodules). Arizona Med 1972;29:775-781.[Medline]
  35. Como JA, Dismukes WE. Oral azole drugs as systemic antifungal therapy N Engl J Med 1994;330:263-272.[Medline]
  36. Stevens DA, Rendon A, Gaona-floves V, et al. Posaconazole therapy for chronic refractory coccidioidomycosis Chest 2007;132:952-958.[Abstract/Free Full Text]



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