ventricular
12
tachycardia
340,
1973
Mathur
PP:
rhythmic 84:764-770, 13
Cardiovascular
agent,
of
a
47 :33 1-
newer
phosphate.
antiar-
Am
J
Heart
1972
Ranney
RE,
Dean
RR,
: Pharmacokinetic
of
new
a
Circulation
effects
disopyramide
phate Tlier
bretylium.
to
Karim
and
antiarrhythmic
A :
agent.
191:162-188,
Disopyramide
pharmacologic Arch
Int
NtIS, Caracta
evaluation
of
780,
Pharmacodyn
1971
14 Yeh BK, Sung PK, Scherlag BJ: Effects on electrophysiological and mechanical heart. J Pharm Sci 62:1924-1929, 1973 15 Josephson
phosrelationships
AR,
Lau
disopyramide
SH:
in
of disopyramide properties of the
Electrophysiological
man.
Am
J 8:771-
Heart
1973
16 Conway
TF,
cardiac
Bottomley
K, Wakelye
arrliythmias:
1:105-114,
An
initial
EJ:
Disopyramide J mt Med
appraisal.
in Res
FIGuRE
1. Tomogram
with
“fungusball.”
solved,
leaving
Pulmonary
Mycetoma
Coccidioides
due
Pulmonary
mycetoma
due
on three report
such
A 26-year-old admitted
to Coccidioides
occasions.
occurring
lesions
in a patient
mycetoma
P
responded
B, resection and
was
present
mycetoma
monly
as
pulmonary
well
widely
dis-
to therapy
with
ampho-
to eliminate
the
residual
hemoptysis.
l)y
tients
have
three primary
recovered
had
or
Candida
chronic
tuberculosis hosts
as
mycetoma
occasions
as a late
pulmonary coccidioidal widely disseminated
a
and
Al-
in
pa-
addition,
multiple
abdomen
and
Departments Martin
Charles H. the University
0
0
California Assistant
tAssistant Associate
§ Fellow
Drew
Schools Professor
of
Professor Professor
of Luther
oppor-
been
sequela
infection.’ disease which
Southern
of Medicine, of Medicine.
in Infectious
Professor Reprint r(’qtlest.s: Los Ang(’le.s 900.5.9
71:
Internal King,
Postgraduate
of
Clinical
CHEST,
lobe
University
the
cavitaty
( Fig
pare-
Dr.
3, MARCH,
1977
South
Wilmington,
rash
of
right and
lower lobe, generalized examination. In observed over the
the
physical were
Cultures
from
these
were
the
the
a
fungus
with
was
1 : 128
in
mass positive
lobes The
in the
then
right the
an
on
lobe
revealed
culture
for
multiple
a collection
and
airand
upper
back
complement-fixation
serum
in the
area
showed
and
de-
and
showed
the on
medium
upper left.
having
thorax
supraclavicular ball
the
contrast
the
films
right
of
which
to 1)0th to
the
readmitted,
posterior
x-ray
in
aspiration
Ofl
the
Chest
of
was
over
mass
material
neck
patient
masses
lesion
1 :4 in the
C
sinus
in the
base
titers
had
cerebrospinal
course of therapy with amphotericin was total, 20 mg intrathecally, and local treatment chest tube inserted for drainage into the area of an ) . Again, the patient improved and was discharged. patient was readmitted in November 1975, with hemoptysis ( up to 500 ml daily ) . Complement tests were negative in both the spinal fluid and A chest x-ray film showed the mycetorna ( fungus
fluid;
a
given
( 1 gui
into
discharged.
areas. in
again
a
The significant
fixation serum.
lobe 12021
on
nodules finger.
was night
a maculopapular in
noted
middle
Injection
second
to
be
‘as
creased
Medicine.
Titadepalli,
California with fever,
hepatosplenomegaly
1974,
leading
time
Diseases.
of
of
and
Pneumonitis
fluctuant
1 ) . Needle
the
ball)
Pathology. of Surgery.
hemoptysis,
fluctuant
level
risen
Medicine, Surgery, and Jr. General hospital, School of Medicine, and
California and Los Angeles.
1973
was
of
fluid
of
of previous
This finally
southern
March,
left
patient
tracts
reported
pulmonary
for
empyema
#{176}From the Pathology,
upper
Coccidioide,s immitis. Further work-up showed involvement of the meninges and multiple bones. The patient was given therapy with amphotericin B ( 2 gm total, as well as 20 mg intrathecally ) . The complement fixation titer was positive in the serum ( 1 : 1,024 ) and the cerebral spinal fluid ( 1 :8 ) . A skin test was positive with a 1 : 100 dilution of coccidioidin. After treatment, tests for complement fixation in both the serum and cerebrospinal fluid had become negative, l)ositive
purulent ini7iiitis.
diabetes,
so-called has
from
in
was
supraclavicular
suppurative and
man
by
‘eloped
or occa-
is seen
from
including
previous
oIl
right
REPORT
black
duration.
In May
corn-
preexisting
of Phycomycetes,
Coccidioidal
.
most
of
characteristically
compromised
event
(K-curs
colonization
species This
disease, other
in
ball)
by Aspergillus
Nocardia,
who
tunistic
tient
a saprophytic
l)oythi.
pulmonary or
(fungus
cavitation
lesclzeria
isolated
an
hospital
lymphadenopathy,
so the ulmonary
sionally
as
mycetoma
loss,
weeks’
accompanied
hyphae were found in pulmonary and extra-
required
its attendant
with
the
weight
five
is the
case
to
sweats,
has
immitis
The
seminated disease. Spherules and the specimen. While the active pulmonary
the
CASE
immitis*
reported
tericin
in
infection.
to
Ilaragopal lIla(Ic’;)alli, M.D.;#{176}#{176} Frank A. Salem, M.D.;f Ashis K. Mandal, M.D., F.C.C.P.; Karnalakar Rambhatla, M.D.; and han-s E. Einstein, M.D., F.C.C.P.
fourth
cavity
1973 residual
been
showing
unchanged.
function.4
was
shown
in
were
seen
A skin
negative,
and Because
resected. Figure
The 2.
microscopically
test
T-cell
Mycelial
with
coccidioidin
stimulation of
hemoptysis,
resected
3 and
and as
at showed
the
lung
elements,
( Fig
tests
right
deupper
niycetoma
well
4 ) , and
as
this
are
spherules,
culture
PULMONARY MYCETOMA DUE TO C IMMITIS
was
429
positive gm
C immitis.
for
of
amphotericin
therapy
consisted
The
patient
during
this
was
given
time.
an
His
additional
total
of 4 gm of amphotericin
1
intravenous
B.
DIscussIoN This
patient
which
had
persisted
widely
disseminated
pleural
space
through
the
nervous
system
tericin
B,
fungus
ball
coecidioidal
though
he was
disease
(with
formation
chest
wall)
with
as
ultimately
a primary
even
involving of
,
as
required
resection
lungs,
and local
the fistula
the
of 4 gm
appropriate unchanged
the
bones,
dosage
remained
to overcome
a bronchopleural
the
a total
well
mycetoma
able
central
of ampho-
therapy.
The
radiographically because
and
of
massive
hemoptysis. The
finding
nary
Puckett’s5
mycelial
elements
lesions
original
theoretic are
of
coccidioidal
has
description,
specter
a constant
finding
clinicians
raising,
of contagion.
as
While
in both
pulmosince
in residual
concerned
the
it
does,
mycelial
sputum
the
elements
and
specimens
of patients
with pulmonary coccidioidal cavitation, dry arthrospores, the actual “infective” portion of the saprophytic cycle, are not found. Contagion, therefore, has never been observed, in spite of diligent search. This
patient
diminished
showed
previously
response,
complement-fixing
tive
the
immune
antibodies)
eoceidioidin
,
test)
skin
disease.
Decreased
T-eell
appears
probable,
therefore,
dioidal
mycetoma
is
reported
both and
cell-mediated
in the
latter
activity
was
that
a
finding
( absent
humoral
(nega-
stages
also
of his
observed.
formation
manifestation
of
of of
It
a cocci-
altered
host
immunity. ACKNOWLEDGMENT:
M.D.,
for
evaluating
We
the
thank
Antonino
immunologic
Catanzaro,
status
of this
patient.
REFERENCES
1 Putnam immiti.s Respir 2
FIGURE
showing
( top )
cavity
.
Hemisectioned
lesion
measuring
right
5 x
upper 4
lobe
of
x 3 cm and ( fungus ball).
lung
nasty
showing
gray-brown
spherules
stain,
grumous
of
material
coccidiodomycosis
mine
silver
original
430
THADEPALLI ET AL
magnification
( Gomori’s x 1,000).
methena-
Harper
Dis
Belgrad
WK, cause
3
R:
Nelson
The
surgical
A,
Spitter
J
coecidioidomycosis.
the
Probl
Curr
Catanzaro
5 Puckett
ball:
TF : Hyphae human
An
Radiology
AR:
human
JFM,
et al:
Coccidoides
mycetoma.
Am
Rev
1975
Fungus
cidioidomycosis.
4
Greene of pulmonary
112:733-738,
coccidioidomycosis.
filled
Surrounding pulmonary parenehyma is indurated. FIGuiu 3 ( center ) . Section of wall of cavity ( shown in Figure 4 and containing fungus ball), showing heavily and lightly stained hyphae with adjacent and superimposed microorganisms ( Gomori’s methenamine silver stain, original magnification x 1,000) . Ficuax 4 ( bottom). Area adjacent to Figure 3, with
2
JS,
: A rare
unusual
manifestation
:289,
101
treatment
Surg
of
Oct,
of
1971 pulmonary
coc-
1974
L,
Moser
KM : Immunotherapy
Clin
Invest
54:690-701,
of Coccidioides host.
Am
Rev
of
1974
immitis
in
Tubere
70:320-327,
tissues
of
1954
CHEST, 71: 3, MARCH, 1977
12
tachycardia
340,
1973
Mathur
PP:
rhythmic 84:764-770, 13
Cardiovascular
agent,
of
a
47 :33 1-
newer
phosphate.
antiar-
Am
J
Heart
1972
Ranney
RE,
Dean
RR,
: Pharmacokinetic
of
new
a
Circulation
effects
disopyramide
phate Tlier
bretylium.
to
Karim
and
antiarrhythmic
A :
agent.
191:162-188,
Disopyramide
pharmacologic Arch
Int
NtIS, Caracta
evaluation
of
780,
Pharmacodyn
1971
14 Yeh BK, Sung PK, Scherlag BJ: Effects on electrophysiological and mechanical heart. J Pharm Sci 62:1924-1929, 1973 15 Josephson
phosrelationships
AR,
Lau
disopyramide
SH:
in
of disopyramide properties of the
Electrophysiological
man.
Am
J 8:771-
Heart
1973
16 Conway
TF,
cardiac
Bottomley
K, Wakelye
arrliythmias:
1:105-114,
An
initial
EJ:
Disopyramide J mt Med
appraisal.
in Res
FIGuRE
1. Tomogram
with
“fungusball.”
solved,
leaving
Pulmonary
Mycetoma
Coccidioides
due
Pulmonary
mycetoma
due
on three report
such
A 26-year-old admitted
to Coccidioides
occasions.
occurring
lesions
in a patient
mycetoma
P
responded
B, resection and
was
present
mycetoma
monly
as
pulmonary
well
widely
dis-
to therapy
with
ampho-
to eliminate
the
residual
hemoptysis.
l)y
tients
have
three primary
recovered
had
or
Candida
chronic
tuberculosis hosts
as
mycetoma
occasions
as a late
pulmonary coccidioidal widely disseminated
a
and
Al-
in
pa-
addition,
multiple
abdomen
and
Departments Martin
Charles H. the University
0
0
California Assistant
tAssistant Associate
§ Fellow
Drew
Schools Professor
of
Professor Professor
of Luther
oppor-
been
sequela
infection.’ disease which
Southern
of Medicine, of Medicine.
in Infectious
Professor Reprint r(’qtlest.s: Los Ang(’le.s 900.5.9
71:
Internal King,
Postgraduate
of
Clinical
CHEST,
lobe
University
the
cavitaty
( Fig
pare-
Dr.
3, MARCH,
1977
South
Wilmington,
rash
of
right and
lower lobe, generalized examination. In observed over the
the
physical were
Cultures
from
these
were
the
the
a
fungus
with
was
1 : 128
in
mass positive
lobes The
in the
then
right the
an
on
lobe
revealed
culture
for
multiple
a collection
and
airand
upper
back
complement-fixation
serum
in the
area
showed
and
de-
and
showed
the on
medium
upper left.
having
thorax
supraclavicular ball
the
contrast
the
films
right
of
which
to 1)0th to
the
readmitted,
posterior
x-ray
in
aspiration
Ofl
the
Chest
of
was
over
mass
material
neck
patient
masses
lesion
1 :4 in the
C
sinus
in the
base
titers
had
cerebrospinal
course of therapy with amphotericin was total, 20 mg intrathecally, and local treatment chest tube inserted for drainage into the area of an ) . Again, the patient improved and was discharged. patient was readmitted in November 1975, with hemoptysis ( up to 500 ml daily ) . Complement tests were negative in both the spinal fluid and A chest x-ray film showed the mycetorna ( fungus
fluid;
a
given
( 1 gui
into
discharged.
areas. in
again
a
The significant
fixation serum.
lobe 12021
on
nodules finger.
was night
a maculopapular in
noted
middle
Injection
second
to
be
‘as
creased
Medicine.
Titadepalli,
California with fever,
hepatosplenomegaly
1974,
leading
time
Diseases.
of
of
and
Pneumonitis
fluctuant
1 ) . Needle
the
ball)
Pathology. of Surgery.
hemoptysis,
fluctuant
level
risen
Medicine, Surgery, and Jr. General hospital, School of Medicine, and
California and Los Angeles.
1973
was
of
fluid
of
of previous
This finally
southern
March,
left
patient
tracts
reported
pulmonary
for
empyema
#{176}From the Pathology,
upper
Coccidioide,s immitis. Further work-up showed involvement of the meninges and multiple bones. The patient was given therapy with amphotericin B ( 2 gm total, as well as 20 mg intrathecally ) . The complement fixation titer was positive in the serum ( 1 : 1,024 ) and the cerebral spinal fluid ( 1 :8 ) . A skin test was positive with a 1 : 100 dilution of coccidioidin. After treatment, tests for complement fixation in both the serum and cerebrospinal fluid had become negative, l)ositive
purulent ini7iiitis.
diabetes,
so-called has
from
in
was
supraclavicular
suppurative and
man
by
‘eloped
or occa-
is seen
from
including
previous
oIl
right
REPORT
black
duration.
In May
corn-
preexisting
of Phycomycetes,
Coccidioidal
.
most
of
characteristically
compromised
event
(K-curs
colonization
species This
disease, other
in
ball)
by Aspergillus
Nocardia,
who
tunistic
tient
a saprophytic
l)oythi.
pulmonary or
(fungus
cavitation
lesclzeria
isolated
an
hospital
lymphadenopathy,
so the ulmonary
sionally
as
mycetoma
loss,
weeks’
accompanied
hyphae were found in pulmonary and extra-
required
its attendant
with
the
weight
five
is the
case
to
sweats,
has
immitis
The
seminated disease. Spherules and the specimen. While the active pulmonary
the
CASE
immitis*
reported
tericin
in
infection.
to
Ilaragopal lIla(Ic’;)alli, M.D.;#{176}#{176} Frank A. Salem, M.D.;f Ashis K. Mandal, M.D., F.C.C.P.; Karnalakar Rambhatla, M.D.; and han-s E. Einstein, M.D., F.C.C.P.
fourth
cavity
1973 residual
been
showing
unchanged.
function.4
was
shown
in
were
seen
A skin
negative,
and Because
resected. Figure
The 2.
microscopically
test
T-cell
Mycelial
with
coccidioidin
stimulation of
hemoptysis,
resected
3 and
and as
at showed
the
lung
elements,
( Fig
tests
right
deupper
niycetoma
well
4 ) , and
as
this
are
spherules,
culture
PULMONARY MYCETOMA DUE TO C IMMITIS
was
429
positive gm
C immitis.
for
of
amphotericin
therapy
consisted
The
patient
during
this
was
given
time.
an
His
additional
total
of 4 gm of amphotericin
1
intravenous
B.
DIscussIoN This
patient
which
had
persisted
widely
disseminated
pleural
space
through
the
nervous
system
tericin
B,
fungus
ball
coecidioidal
though
he was
disease
(with
formation
chest
wall)
with
as
ultimately
a primary
even
involving of
,
as
required
resection
lungs,
and local
the fistula
the
of 4 gm
appropriate unchanged
the
bones,
dosage
remained
to overcome
a bronchopleural
the
a total
well
mycetoma
able
central
of ampho-
therapy.
The
radiographically because
and
of
massive
hemoptysis. The
finding
nary
Puckett’s5
mycelial
elements
lesions
original
theoretic are
of
coccidioidal
has
description,
specter
a constant
finding
clinicians
raising,
of contagion.
as
While
in both
pulmosince
in residual
concerned
the
it
does,
mycelial
sputum
the
elements
and
specimens
of patients
with pulmonary coccidioidal cavitation, dry arthrospores, the actual “infective” portion of the saprophytic cycle, are not found. Contagion, therefore, has never been observed, in spite of diligent search. This
patient
diminished
showed
previously
response,
complement-fixing
tive
the
immune
antibodies)
eoceidioidin
,
test)
skin
disease.
Decreased
T-eell
appears
probable,
therefore,
dioidal
mycetoma
is
reported
both and
cell-mediated
in the
latter
activity
was
that
a
finding
( absent
humoral
(nega-
stages
also
of his
observed.
formation
manifestation
of
of of
It
a cocci-
altered
host
immunity. ACKNOWLEDGMENT:
M.D.,
for
evaluating
We
the
thank
Antonino
immunologic
Catanzaro,
status
of this
patient.
REFERENCES
1 Putnam immiti.s Respir 2
FIGURE
showing
( top )
cavity
.
Hemisectioned
lesion
measuring
right
5 x
upper 4
lobe
of
x 3 cm and ( fungus ball).
lung
nasty
showing
gray-brown
spherules
stain,
grumous
of
material
coccidiodomycosis
mine
silver
original
430
THADEPALLI ET AL
magnification
( Gomori’s x 1,000).
methena-
Harper
Dis
Belgrad
WK, cause
3
R:
Nelson
The
surgical
A,
Spitter
J
coecidioidomycosis.
the
Probl
Curr
Catanzaro
5 Puckett
ball:
TF : Hyphae human
An
Radiology
AR:
human
JFM,
et al:
Coccidoides
mycetoma.
Am
Rev
1975
Fungus
cidioidomycosis.
4
Greene of pulmonary
112:733-738,
coccidioidomycosis.
filled
Surrounding pulmonary parenehyma is indurated. FIGuiu 3 ( center ) . Section of wall of cavity ( shown in Figure 4 and containing fungus ball), showing heavily and lightly stained hyphae with adjacent and superimposed microorganisms ( Gomori’s methenamine silver stain, original magnification x 1,000) . Ficuax 4 ( bottom). Area adjacent to Figure 3, with
2
JS,
: A rare
unusual
manifestation
:289,
101
treatment
Surg
of
Oct,
of
1971 pulmonary
coc-
1974
L,
Moser
KM : Immunotherapy
Clin
Invest
54:690-701,
of Coccidioides host.
Am
Rev
of
1974
immitis
in
Tubere
70:320-327,
tissues
of
1954
CHEST, 71: 3, MARCH, 1977
