- Email: [email protected]
Pulmonary Blastomycosis Diagnosed by Thoracocentesis
CoMMENT 1 Genovesi MG, Simmons DH: Airway obstruction due to spontaneous retropharyngeal hemorrhage. Chest 68:840842,1975 2 Owens DE, Calcaterra TC, Aarstad RA: Retropharyngeal hematoma: A complication of therapy with anticoagulants. Arch 0t0Iaryngoll01:565-568, 1975 3 Lepore ML: Upper airway obstruction induced by warfarin sodium. Arch Otolaryngoll02:505-506, 1976
Pulmonary Blastomycosis Diagnosed by Thoracocentesis To the Editor:
Pleural elusions in blastomycosis are
uneommOn.1,1
We
describe a case of blastomycosis in which the diagnosis was made by direct examination of pleural fluid.
A 38-year-old black woman was admitted to a local hospital complaining of a three-day history of left lateral pleuritic chest pain. Low-grade fever and nonproductive cough had been present for several weeks, and a ten pound weight loss had occurred over the preceding two months. A chest roentgenogram revealed a left perihilar infiltrate. She was treated with multiple antibiotics, but remained febrile to agoC, and the chest roentgenogram showed extension of the infiltrate to include the entire left lower lobe. She was transferred to our hospital. She appeared acutely ill, but was alert and oriented. Examination of the chest revealed dullness to percussion and decreased breath sounds on the left to the angle of the scapula. A pleural friction rub was present on the left. The hematocrit was 28.6 percent and the white cell count was 13,900/cu mm with 73 segmented forms and 8 bands. The chest roentgenogram revealed a left lower lobe infiltrate, and a large left pleural effusion was confirmed with a left lateral decubitus film. Thoracocentesis produced yellow, cloudy fluid with the following charactEristics : protein 4.2 gm/dl, glucose 221 mg/dl, red blood cells 22OO/cu mm, white blood cells 1,640/ cu mm with 50 percent mononuclear cells and 50 percent polymorphonuclear cells. A wet mount of the pleural fluid contained numerous oval, doubly refractile organisms, many of which had single, broad-based buds (Fig 1 ). Culture of the pleural fluid was subsequently positive for B'lostomycu clermatitidis. The patient was treated with a total of 1500 mg amphotEricin B with rapid subjective improvement and clearing of the chest roentgenogram.
The chest roentgenogram in pulmonary blastomycosis is nonspecific.l,z The disease may occur anywhere in the lungs and may appear as homogeneous pneumonic infiltrates with a segmental or lobar distribution, as patchy reticulonodular inftItrates. as diffuse nodular infiltrates, or as miliary infiltrates. Cavitary lesions, hilat and mediutinal lymphadenopathy and pleural thicke~g are also described.1 •Z Although pleural thickening is commonly lIeeD (10 of 25 patients in the study by Hawley and FelsonS ) pleural effusions are lIDCllIDmon. I •2 In the VA cooperative study,4 only 4 of the 198 cue( had roentgenographically detectable pleural effusions, . . only one had a positive pleural fluid culture. In a ~~ . review of 50 cases, "pleural reaction" was present in 1:1;:" . patients, but cultures of fluid obtained at thora~ ,.Y ~ .~
were positive inonly four cuea. 0
Our patient with blastomycosis developed a ~ pleura) effusion that was not • culture-positive, but also smearpositive. Beca8Ie results of C:olture of the organism usually requires two to three weeb,1 direct uamination of pleural ~ should be Rdid for the yeast form of B~ included in the evaluation of patients from endemic areas who develop pleural effusions of unknown etiology.
1 - L. HMgi8, M.D.; Roger C. Bone,M.D., F.C.CP., F. Chotl& MIllst, M.D., F.C.CP.; Frank 1.WiUon, M .D., Deparlmenl of Medicine, UnitJerIity ofArktmatu College of Medicine, Little Rock Reprint requem: Dr. ~/
U~
of ArkamCII Medical
Sciences, 4301 West MtJrfWIm, LUtle Rock 72201
REn:lmNCES 1 O'Neill RP, Penman RWB: Clinical aspects of blastomycosis. Thorax 25:708-715, 1970 2 Witorsch P, Utz }p: North American blastomycosis: a study of 40 patients. Medicine 47: 169-200, 1968 3 Hawley C, Felson B: Roentgen aspects of intrathoracic blastomycosis. Am J Roentgenol Rad Ther 75:751-757. 1956 4 Blastomycosis Cooperative Study of the VA: Blastomycosis: a review of 198 collected cases in VA hospitals. Am Rev Respir Dis 89:659-672, 1964 5 Cwh R, Light RW, George RB: Clinical and roentgenographic manifestations of acute and chronic blastomycosis. Chest 69:345-394, 1976
Spontaneous Pneumothorax as a Presenting Pulmonary Manifestation of Early Sarcoidosis To the Editor :
1. Wet mount of pleural Ruid containing oval, doubly refractile organisms with single, broad-based buds.
FICURE
CHEST, 77: 3, MARCH, 1980
A 25-year-old black woman was hospitalized in another hospital in January 1975 because of fever and weight loss. No abnormalities were detected by physical eumination and chest roentgenograms. Senmi aDcaline phosphatalJe was elevated and a liver biopsy showed multiple noncaseatlng granulomas, but no definitE diagnosis could be made and the patient was discharged without therapy. On July 13, 1976, the same patient was admitted to San Francisco General Hospital Medical Center because of leftsided chest pain and severe dyspnea. The chest roentge~ grams showed left-sided pneumothoru: and bilateral
COMMUNICATIONS TO THE EDITOR 455
·
Pulmonary Blastomycosis Diagnosed by Thoracocentesis To the Editor:
Pleural elusions in blastomycosis are
uneommOn.1,1
We
describe a case of blastomycosis in which the diagnosis was made by direct examination of pleural fluid.
A 38-year-old black woman was admitted to a local hospital complaining of a three-day history of left lateral pleuritic chest pain. Low-grade fever and nonproductive cough had been present for several weeks, and a ten pound weight loss had occurred over the preceding two months. A chest roentgenogram revealed a left perihilar infiltrate. She was treated with multiple antibiotics, but remained febrile to agoC, and the chest roentgenogram showed extension of the infiltrate to include the entire left lower lobe. She was transferred to our hospital. She appeared acutely ill, but was alert and oriented. Examination of the chest revealed dullness to percussion and decreased breath sounds on the left to the angle of the scapula. A pleural friction rub was present on the left. The hematocrit was 28.6 percent and the white cell count was 13,900/cu mm with 73 segmented forms and 8 bands. The chest roentgenogram revealed a left lower lobe infiltrate, and a large left pleural effusion was confirmed with a left lateral decubitus film. Thoracocentesis produced yellow, cloudy fluid with the following charactEristics : protein 4.2 gm/dl, glucose 221 mg/dl, red blood cells 22OO/cu mm, white blood cells 1,640/ cu mm with 50 percent mononuclear cells and 50 percent polymorphonuclear cells. A wet mount of the pleural fluid contained numerous oval, doubly refractile organisms, many of which had single, broad-based buds (Fig 1 ). Culture of the pleural fluid was subsequently positive for B'lostomycu clermatitidis. The patient was treated with a total of 1500 mg amphotEricin B with rapid subjective improvement and clearing of the chest roentgenogram.
The chest roentgenogram in pulmonary blastomycosis is nonspecific.l,z The disease may occur anywhere in the lungs and may appear as homogeneous pneumonic infiltrates with a segmental or lobar distribution, as patchy reticulonodular inftItrates. as diffuse nodular infiltrates, or as miliary infiltrates. Cavitary lesions, hilat and mediutinal lymphadenopathy and pleural thicke~g are also described.1 •Z Although pleural thickening is commonly lIeeD (10 of 25 patients in the study by Hawley and FelsonS ) pleural effusions are lIDCllIDmon. I •2 In the VA cooperative study,4 only 4 of the 198 cue( had roentgenographically detectable pleural effusions, . . only one had a positive pleural fluid culture. In a ~~ . review of 50 cases, "pleural reaction" was present in 1:1;:" . patients, but cultures of fluid obtained at thora~ ,.Y ~ .~
were positive inonly four cuea. 0
Our patient with blastomycosis developed a ~ pleura) effusion that was not • culture-positive, but also smearpositive. Beca8Ie results of C:olture of the organism usually requires two to three weeb,1 direct uamination of pleural ~ should be Rdid for the yeast form of B~ included in the evaluation of patients from endemic areas who develop pleural effusions of unknown etiology.
1 - L. HMgi8, M.D.; Roger C. Bone,M.D., F.C.CP., F. Chotl& MIllst, M.D., F.C.CP.; Frank 1.WiUon, M .D., Deparlmenl of Medicine, UnitJerIity ofArktmatu College of Medicine, Little Rock Reprint requem: Dr. ~/
U~
of ArkamCII Medical
Sciences, 4301 West MtJrfWIm, LUtle Rock 72201
REn:lmNCES 1 O'Neill RP, Penman RWB: Clinical aspects of blastomycosis. Thorax 25:708-715, 1970 2 Witorsch P, Utz }p: North American blastomycosis: a study of 40 patients. Medicine 47: 169-200, 1968 3 Hawley C, Felson B: Roentgen aspects of intrathoracic blastomycosis. Am J Roentgenol Rad Ther 75:751-757. 1956 4 Blastomycosis Cooperative Study of the VA: Blastomycosis: a review of 198 collected cases in VA hospitals. Am Rev Respir Dis 89:659-672, 1964 5 Cwh R, Light RW, George RB: Clinical and roentgenographic manifestations of acute and chronic blastomycosis. Chest 69:345-394, 1976
Spontaneous Pneumothorax as a Presenting Pulmonary Manifestation of Early Sarcoidosis To the Editor :
1. Wet mount of pleural Ruid containing oval, doubly refractile organisms with single, broad-based buds.
FICURE
CHEST, 77: 3, MARCH, 1980
A 25-year-old black woman was hospitalized in another hospital in January 1975 because of fever and weight loss. No abnormalities were detected by physical eumination and chest roentgenograms. Senmi aDcaline phosphatalJe was elevated and a liver biopsy showed multiple noncaseatlng granulomas, but no definitE diagnosis could be made and the patient was discharged without therapy. On July 13, 1976, the same patient was admitted to San Francisco General Hospital Medical Center because of leftsided chest pain and severe dyspnea. The chest roentge~ grams showed left-sided pneumothoru: and bilateral
COMMUNICATIONS TO THE EDITOR 455
·