Surgical management of non-mycobacterial fungal infections

Abstract

Fungal infections of the lung are common in endemic areas and in immunocompromised patients. Antifungal therapy is the cornerstone of medical therapy for most pulmonary fungi but surgery is an important adjunct in cases of complicated disease or resistant organisms. A multidisciplinary approach including pulmonary medicine, infectious disease, interventional radiology, and thoracic surgery is favored. This article reviews the surgical management of common fungal pulmonary infections and their sequelae.

Keywords: Fungus; cavitary; infection; lung; surgical management.

Figure 1

Surgical lung specimen from a patient with allergic bronchopulmonary aspergillosis (ABPA) and bronchiectasis. The specimen shows an aspergilloma within the area of saccular bronchiectasis.

Figure 2

Complex right upper lobe aspergilloma in a cavitary lesion with destruction of adjacent lung parenchyma.

Figure 3

Pulmonary coccidioidomycosis. (A) Acute pulmonary coccidioidomycosis infection in a kidney transplant patient showing left upper lobe consolidation; (B) evolution of the left upper lobe consolidation into a central thick walled cavity despite antifungal therapy in the same post-transplant patient.

Figure 4

Coccidioidomycosis empyema. (A) Peripheral left lower lobe coccidioidomycosis cavity with evidence of perforation into the pleural space resulting in a small hydropneumothorax; (B) progression of the hydropneumothorax with pleural fluid cultures positive for coccidioidomycosis; (C) robotic decortication of the left coccidioidomycosis empyema. There is a significant pleural rind encompassing the entire left lung; (D) surgical specimen from the completed decortication. The uppermost specimen is the wedge resection of the left lower lobe where the perforated cavity was located. The remainder of the tissue is the visceral pleural rind which was removed from the lung to allow re-expansion.

Figure 5

Chronic destructive pulmonary coccidioidomycosis of the left lung. There is complete obliteration of the left pulmonary parenchyma with associated pleural changes. There is contraction of the left hemothorax resulting in mediastinal shift. This patient also had significant left hemidiaphragm elevation from the pulmonary retraction.

Figure 6

Pulmonary nodule caused by a prior histoplasmosis infection. The nodule enlarged over time and was avid on PET scan in a previous smoker with no history of fungal infection. Percutaneous biopsy was non-diagnostic. Surgical removal with a minimally invasive wedge resection was performed to rule out malignancy.

Figure 7

Broncholithiasis. (A) Bronchoscopy image in patient with broncholithiasis presenting with hemoptysis. A broncholith is seen in the right lower lobe segmental bronchus; (B) CT chest image corresponding with the broncholith visualized on bronchoscopy. The calcified area in the right lower lobe abuts both the right lower lobe airway and the associated pulmonary arteries.

Figure 8

Pulmonary mucormycosis. (A) CT image of left lower lobe mucormycosis in a heart transplant recipient. The patient received a thoracotomy with left lower lobectomy and intercostal muscle flap to the bronchial stump; (B) surgical specimen (left lower lobectomy) with visualization of the mucormycosis cavity. There is extensive necrosis due to the angioinvasive nature of the fungus.