Video-assisted thoracoscopic surgery for patients with pulmonary coccidioidomycosis

Objective: The study objective was to evaluate the use of video-assisted thoracoscopic surgery for removal of pulmonary sequelae of the fungal infection coccidioidomycosis.

Methods: Retrospective chart review of all patients with pulmonary coccidioidomycosis treated surgically at our tertiary care center between January 1, 2009, and August 31, 2012.

Results: Of 2166 patients treated for pulmonary coccidioidomycosis, 58 (2.7%) (median age, 52 years [range, 18-84 years]) required surgical treatment. Surgical resection was performed for diagnosis (n = 28 [48%]); 17 with positive positron emission tomography findings); persistent or progressive symptoms despite antifungal therapy (n = 23 [40%]); or complications (n = 7 [12%] of cavity rupture/infection). Of 33 patients (57%) who had serology performed, 23 (70%) had positive results. Video-assisted thoracoscopic surgery was used for most (95%; n = 55) procedures, including 38 (67%) wedge resections, 14 (24%) segmentectomies, and 6 (11%) lobectomies; 4 patients also required additional decortication. Major (8%), including 1 death, and minor (12%) complications occurred in 12 patients postoperatively. Median hospitalization was 3 days (range, 1-8 days). Postoperative antifungal therapy was administered to 50% of patients for a median duration of 2 months. No patient had recurrent coccidioidomycosis at a median follow-up of 19 months.

Conclusions: Although rarely necessary for pulmonary coccidioidomycosis, surgical intervention may be indicated. Specific indications include refractory symptomatic disease and complications of the infection, such as cavity rupture. Excisional biopsies also may be required for diagnostic confirmation of indeterminate pulmonary nodules. With video-assisted thoracoscopic surgery, diagnostic and therapeutic intervention can be undertaken with a low risk of complications and shorter length of hospital stay.