Unusual case of pyopneumothorax in Tennessee
Abstract: Rupture of a coccidioidal pulmonary cavity with subsequent pyopneumothorax is a rare clinical event, even in areas endemic for coccidioidomycosis. Our encounter with a patient diagnosed with this condition in northeast Tennessee serves notice to clinicians that coccidioidomycosis is indeed a traveling fungal disease, and practitioners must be alert to common and uncommon manifestations of infection associated with this fungus. A literature review pertaining to coccidioidal pyopneumothorax revealed that patients usually present with a recent onset of chest pain. Serologic testing and pleural fluid culture are highly useful, and management includes surgical intervention with or without antifungal therapy.
Key Words: Coccidioidomycosis, empyema, pulmonary cavity, pyopneumothorax
Although coccidioidomycosis is considered endemic to the southwestern region of the United States, it has also been referred to as the traveling fungal disease, (1) as illness caused by Coccidioides spp has been recorded in nonendemic parts of the United States and other countries. Certain occupations such as long-distance truck driving, tourism, and military assignments allow individuals from various sections of the country or other parts of the world to come into contact with this soil-dwelling fungus, even during brief visits to endemic areas. (1) In this regard, various authors (1-5) have encouraged practicing clinicians to be alert to the characteristics of Coccidioides spp infection, including both the usual and unusual disease presentations. On rare occasions, coccidioidomycosis may present as empyema with hydropneumothorax and this can pose a diagnostic dilemma even for clinicians practicing in endemic areas. (6) Our interaction with a Tennessee resident who had pyopneumothorax caused by Coccidioides immitis encouraged us to review the literature pertaining to this unusual entity and report the case, as it represents an excellent example of this traveling fungal disease.
A 70-year-old retired long-distance truck driver was admitted to a Johnson City, Tennessee, hospital complaining of the sudden onset of shortness of breath and sharp, right-sided chest pain. He reported no fever, sweats, anorexia, weight loss, or hemoptysis. His medical history was positive for coronary artery disease, hypertension, chronic obstructive pulmonary disease, rheumatoid arthritis that required prednisone therapy for several months, and a history of positive tuberculin skin test for which he had received appropriate treatment. Social history was positive for previous tobacco use. He was a retired long-distance truck driver, and his work brought him to the southwest region of the United States on several occasions. Chest radiography at the time of admission showed apical bullae and a small right pneumothorax. His chest pain and shortness of breath improved, and he was discharged after a few days without undergoing further studies or interventions. Within 1 week's time, however, the patient's right-sided chest discomfort recurred and he was readmitted to the hospital. Physical examination revealed dullness to percussion and diminished breath sounds over the...
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