Coccidioidal pulmonary cavities with rupture.

Twenty-three patients with spontaneous rupture of a pulmonary cavity with a pyopneumothorax resulting from coccidioidomycosis are presented. Clinical and laboratory findings, medical and surgical treatment, and complications are detailed. Skin tests are not helpful in making a diagnosis. Although complement fixation titers were elevated in all patients and cultures were positive in 21, these laboratory tests should not delay surgical treatment. Surgical treatment included seven lobectomies, thirteen partial lobectomies, and one pneumonectomy. Two patients did not undergo surgical resection. Seventeen required some degree of decortication. There were three major complications and no deaths. Prompt operation is recommended when the diagnosis is suspected. Reasons for postponement include delay in seeking treatment, poorly controlled diabetes, and other complicating medical factors. The extent of surgical resection may have to be limited because of the extensive contamination of the pleural space. Amphotericin B was administered in 10 patients. The drug should be administered when the cavity ruptures in the acute phase of the disease, in all patients with diabetes, in delayed operations, in patients with concomitant medical problems, and when the extent of resection is limited to obtain immediate obliteration of the pleural space.