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Surgical pathology of pleural coccidioidomycosis: a clinicopathological study of 36 cases
Tatyana A Shekhel1, Robert W Ricciotti2, Janis E Blair3
1Department of Internal Medicine, University of Arizona, Tucson, AZ 85741, USA.
Abstract:
Most pulmonary coccidioidal infections are intraparenchymal; the pleurae are rarely involved. Pleuritis is a recognized complication of ruptured cavitary infections and occasionally occurs in other settings but has not been fully characterized. To define the clinical and histopathologic characteristics of pleural coccidioidomycosis as encountered by surgical pathologists, we reviewed the clinical history, imaging, and histology of 36 biopsy-, resection-, or autopsy-confirmed cases (with coccidioidal spherules present in pleural tissue; median age, 39 years; 22 men). These represented 7% of all pulmonary coccidioidal infections and showed 2 modes of presentation, including ruptured cavitary infection (26) and pleural-predominant disease with milder parenchymal involvement (10). Risk factors included immunodeficiency, smoking, and occupational exposure to soil. Common symptoms (median, 5 weeks) included cough (47%), chest pain (44%), and dyspnea (39%). Imaging often showed pleural adhesions (64%) and effusions (61%). Treatment included lobectomy or decortication, with antifungal medications. All cases showed granulomatous pleuritis. Both modes of presentation showed similar histologic features, including the composition of inflammatory infiltrates, degree of fibrosis, and extent of necrosis. Spherules were usually few (mean density, <1/10 high-power field). Three deaths occurred (all with ruptured cavities); the remaining patients recovered. Differential diagnosis of pleural effusions should include coccidioidomycosis, particularly in endemic areas, even without significant intrapulmonary disease. Most cases of coccidioidomycotic pleuritis are encountered by pathologists after resection of ruptured cavities with decortication, but pleural-predominant infections may be biopsied for diagnostic purposes. Spherules are usually rare in pleural tissue, and liberal sampling, cultures, or serologic studies may be required to confirm the diagnosis.
Insights
Pleural coccidioidomycosis, a rare complication of fungal lung infection, presents as ruptured cavities or primary pleural disease. Diagnosis can be challenging due to rare fungal spherules in pleural tissue.
Area of Science:
- Infectious Diseases
- Pulmonology
- Pathology
Background:
- Pulmonary coccidioidomycosis typically involves lung tissue, with pleural involvement being uncommon.
- Pleural coccidioidomycosis (pleuritis) is a recognized complication, often associated with ruptured cavitary infections, but its characteristics are not fully understood.
Purpose of the Study:
- To define the clinical and histopathologic features of pleural coccidioidomycosis in cases confirmed by surgical pathology.
- To characterize the presentation, risk factors, symptoms, imaging findings, and histology of pleural coccidioidomycosis.
Main Methods:
- Retrospective review of 36 confirmed cases of pleural coccidioidomycosis.
- Analysis included clinical history, imaging, and histopathologic examination of pleural tissue for coccidioidal spherules.
Main Results:
- Pleural coccidioidomycosis represented 7% of pulmonary infections, with two presentations: ruptured cavitary infection (26 cases) and pleural-predominant disease (10 cases).
- Common symptoms included cough, chest pain, and dyspnea; imaging showed adhesions and effusions. All cases exhibited granulomatous pleuritis, with rare spherules (<1/10 HPF).
- Three deaths occurred, all in patients with ruptured cavities; others recovered with treatment (surgery and antifungals).
Conclusions:
- Coccidioidomycosis should be considered in the differential diagnosis of pleural effusions, especially in endemic areas, even with minimal lung disease.
- Histologic confirmation can be difficult due to sparse spherules, necessitating thorough sampling, cultures, or serology.
- Surgical pathology plays a key role, particularly in diagnosing cases post-resection for ruptured cavities or via biopsy for pleural-predominant forms.
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