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Pulmonary Function in Paracoccidioidomycosis (South American Blastomycosis)
When the patient turned onto his right side, further IW1'0Wing rlthe left main-stem bronchus was observed. DISCUSSION
'l1rls report demonstrates the development ofdyspnea and oxygen desaturation related to partial mechanical obstruc-tion of the left main-stem bronchus when the patient lay on his right side. We believe that these changes are due to the eft'ects ofgravity on the mass originating in the left upper lobe surgical stump. With the patient in the left lateral position, the mass was inferior or lower than the left main bronchus and would not affect its patency. In contrast, in the right lateral position, gravity caused the mass to protrude further into the airway of the left main-stem bronchus and thereby decrease ventilation to the left lower lobe. Conceivably, this led to hypoxemia based on low ventilation-perfusion matching in the left lower lobe. Because the patient's symptoms developed immediately upon turning onto his right side, we believe that the mechanism of the tachypnea and dyspnea was mechanical rather than related to desaturation. In patients with unilateral lung disease, such as atelectasis or pneumonia, inwlving either the right or left lung, Remolina and colleagues• noted that lower arterial oxygen tension occwred when the inwlved "sick" lung was dependent as opposed to the lateral position with the "good" lung dependent. Three of the nine patients had primary bronchogenic or metastatic carcinoma inwlving the lung. The authors postulated that these changes were due to ventilationperfusion mismatching associated with the gravitational inftuences on pulmonary blood flow. Our patient also had bronchogenic carcinoma, but there was no evidence of wlume loss or an alveolar &lling process on the chest roentgenogram. Fiberoptic bronchoscopic study demonstrated that partial mechanical obstruction contributed to his positional symptoms and oxygen desaturation rather than increased perfusion to dependent lungs with impaired ventilation. The information obtained in the investigation of our patient provided a physiologic understanding of his complaints and led to an early diagnosis prior to any radiologic changes. Localized radiation therapy was then instituted. Our results showed that oxygenation worsened when the patient was in the lateral position with his "good" or noninwlved lung dependent, and thus "up with the good lung" was most appropriate for his condition. Furthermore, this experience demonstrates the importance of careful interpretation of positional symptoms and physiologic alterations in such patients. REFERENCES
1 Blair E, Hickman JB. The eft'ect rlchange in body position on lung wlume and intrapulmonary gas mixing in normal subjects. J Clio Inwst 1955; 34:383-89 2 Robin ED, Hom B, Goris ML, Theodore J, Van Kessel A, Mazoub
J, et al. Detection, quantification, and pathophysiology rllung "spiders." 1rans Assoc Am Physicians 1975; 88:202-16 3 Robin ED, Laman D, Hom BR, Theodore J. Platypnea related to orthodeozia caused by true vascular lung shunts. N Engl J Med 1981; 294:941-43
4 &molina C, Khan AV, Santiago Tv, Edelman NH. Positional
hypoxemia in unilateral lung disease. N Eng! J Med 1981; 3«N:523-5 5 Fishman AP. Down with the good lung (Editorial~ N Engl J Med 1981; 3«N:537-38
Pulmonary Function In Paracoccldloldomycosls (South American Blastomycosis)* An Analysis of the Obstructive Defect Alfred Lsml., M.D.;t Bodo Wa..U, M.D.;:!: }014 U.boa Mnntla, M.D.;I Gullherme Loja Kropf, M.D.; Mor- Bernardo Mtmtld, M.D.,-J tmd StJmUei MantW, M.D .• Comparison or the mean results or routine pulmonary £unction studies or 17 patients with difl'use pulmonary paracoccidioidomyeosis (PM) and manifestations or chronic obstructive pulmonary disease (COPD) to those of 17 matebed patients with pure COPD sbowecl no signi&cant difl'ereoees. 1bese flnclinp were interpreted as fresh eviclence suggesting that apiratory obstruction in PM may be secondary to underlying COPD. Other eviclence to that
effect is discussed.
T
he lung is involved in almost all patients with paracoccidioidomycosis (PM~ one of the most important systemic mycoses in much of Latin America. There is usually a diffuse, polymorphic granulomatous pneumonitis, with in<rations, areas of consolidation, and occasional small-sized cavitation. Residual fibrotic streaking is common, particularly after treatment." Studies of pulmonary function most often show a predominantly obstructive defect, usually with hypoxemia of varying degree and mechanisms. ' 7 Since patients with PM are practically always mature male fiumhands who smoke, obstruction may be caused by underlying chronic obstructive pulmonary disease (COPD). This fact has not been generally considered, and care Cor patients with PM frequently consists exclusively of fungicidal treatment. Since nonsmoking patients with PM are exceedingly rare, we undertook to study the relative contribution of nonspeci&c obstruction due to COPD in patients with PM who have manifestations of COPD by comparing the pulmonary function of patients with PM who have manifestations of COPD (PMCOPD) to those of matched patients with pure COPD. MATERIALS AND METHODS
1be patients with PMCOPD were selected from a population rl34 parasitologically pi'OIIell cases consecutively seen at our laboratory. 1be patients with COPD were drawn from our &les. Selection was based on the possibiJity rl matching a pair rl patients from each group on the basis rl sa, age, the degrees rl dyspnea, clinical hyperinflation, and, on Inspiratory and expiratory x-ray studies, the decrease rl diaphragmatic motion and the presence rl air trapping. *From the Deparbnents rl Internal Medicine and Prewmtiw Medicine, the Federal Uniwrsity at Rio de Janeiro School rl Medicine, Rio de Janeiro, Brazil. tAssociate Pniessof rllntemal Medicine. :!:Assistant Professor rl PreYentiw Medicine. IM~logist Research Institute, Uniwnidacle Cama Filho. UStri&' An~logist, Conemmaugb Valley Memorial Hospital, . Johnstown. Pa. fChie£ Department rl Anesthesia, Medical Center rl Macon, Macon, Ca. &print ~: Dr. LsmJ., RUG FatJ.l FatJ.l 20, ap l«JJ, Rio d. jaf!No, R.]., Bnml22430 CHEST I 83 I 5 I MAY, 1883
127
Smoldng habits were the same in seven pairs, the patient with PMCOPD smoked slightly more in two, and the patient with COPD smoked more in seven. In one, infOrmation was not euct (total, 17 pairs).
Spirometric studies were perfOrmed on a 9-L water spirometer coupled to a helium analyzing catharometer (Pulmonet; Godart). Samples rl arterial blood and expired air were analyzed lOr respiratory gases and pH on the Clark and Severingbaus electrodes according to previously discussed methods. • The &actional uptake rl carbon monoxide (FCO). calculated as the &action rlinspired carbon monoxide minus the &action rl expired carbon monoxide divided by the &action rl inspired carbon monoxide times 100, was determined with a commercially available apparatus (Diffusiontest; Godart) which measures the diffusing capacity by the steady-state end-tidal sampling method. REsui.IS
The patients with PMCOPD had a slightly higher mean furced expiratory volume in one second over the ratio ~the vital capacity (FEV1NC; 51.8±15.2 percent vs 46.8±16. 7 percent~ predicted), a lower mean VC (83.8 ± 20.2 percent vs 93.2±30.1 percent) and a slightly lower mean residual volume (RV; 171.7±56.4 percent vs 197.3±59.3 percent) than their counterparts with COPD; howeve~; none of these differences was significant at the 5 percent level. The FEV./VC was higher in the patient with PMCOPD in 11 pairs and in the patient with COPD in one pail; and was equal in five pairs. The VC was larger in the patient with PMCOPD in six pairs and in the patient with COPD in seven, and was equal in fuur pairs. The RY, available lOr 13 pairs, was larger in the patient with PMCOPD in fuur pairs and in the patient with COPD in eight pairs, and was equal in one pair. Because ~ missing data points, gas transfer parameten were confronted by a simple comparison of means, in a nonmatched fashion. Mean resting arterial oxygen tension (PaO.), available in 15 patients with PMCOPD and five patients with COPD, was 76.8±14.1 mm Hg and 77.2±3.1 mm Hg, respectively. Mean Pa01 after breathing pure oxygen, available in 13 patients with PMCOPD and five patients with COPD, was 528.7 ± 76.5 mm Hg and 560.0±44.7 mm Hg, respectively. Mean FCO, available in fuur patients in each group, was 46.7±6.8 percent fur the patients with PMCOPD and 47.5±4.4 percent fur the patients with COPD. None ~the differences between these means was significant at the 5 percent level. DISCUSSION
The absence of significant differences between the means the results of pulmonary function tests of patients with PMCOPD and with COPD suggests that the changes in the group with PMCOPD may be due to underlying obstruction rather than to the coexisting in6ltrates. One may speculate that ifthe mycotic inftammation had a considerable impact on function, the results in the patients with PMCOPD should be different from those of comparable patients with COPD. These findings agree with conclusions tentatively drawn from other evidence, namely the lack of endoscopic' or pathologicl data showing mycotic bronchial lesions capable of ~
828
causing manifestations ofCOPD. Autopsies are rare because patients are usually lost to fullow-up, as they return to their villages after therapy. In one ~our few autopsied cases, that ~ a treated man with diffuse fibrosis on the x-ray 6lm, bronchi were carefully studied down to the terminal bronchioli, and only typical nonspecific lesions of chronic bronchitis were fuund. Tests ~ pulmonary function befOre and after specific treatment"-111 show no consistent change in obstruction, even with significant radiologic clearing. The decisive data would, ~course, be fuund in the study of nonsmoking patients free ~COPD. These are very rare. In the literature, conelation functional changes to the smoking status in PM has not been reported regularly by othen. The only nonsmoking patient in our series (also the only woman) had a normal spirogram (VC of 3,280 ml, 107 percent of predicted, and FEV1 of2,430 ml, 75 percent ~VC). The only evidence fur a relationship between PM and COPD comes from Lima Neto, u who fuund that basilar bullae may be prominent and may develop rapidly in patients some special with PMCOPD, suggesting the presence~ emphysema-fOrming mechanism in PM.
m
REFERENCES 1 Fialho AS. Localiza9"\es pulmonares de micose de Lutz: anatomia patolcSgica e patogenia (thesis). Rio de Janeiro: Faculdade
Nacional de Medicina da Universidade do Brasil, 1946 2 Saltelder K, Doehnert G, Doehnert HR. Paracoccidioidomycosis: anatomic study with complete autopsies. Virchow's Arch (Pathol Anat) 1969; 348:51-76 3 Machado Filho J; Lisboa Miranda J. Conside~s relativas l blastomicose sui-americana: da ~ pulmonar entre 338 casos consecutiws. Hospital1960; 58:431-49 4 Hestrepo A, Bobledo M, Guti6rrez F. Sanclemente M, Casta6eda E, Gallo G. Paracoccidioidomycosis (South American blastomycosis): a study rl39 cases observed in Medellin, Colombia. Am J 'liop Med Hyg 1970; 19:68-76 5 Londero AT. The lung in paracoccidioidomycosis. In: Panlcoocidioidomycosis (PHO scienti&c publication 254~ \\Uhington, DC, Pan American Health Organization, 1972;109-17 6 Lemle A, Vieira LOBO, Milward GAF, Lisboa Miranda J. Lung function studies in pulmonary South American blastomycosis: correlation with clinical and roentgenologic findings. Am J Mecl 1970; 48:434-72 7 AfOnso JE, Nery LE, Bomaldini H, Bogossian M, RibeiroRatto a Fun~ pulmonar na paracoccidioidomicose (bJasto. micose sui-americana~ 8ev Inst Med li"Op Slo Paulo 1979; 21:269-80 8 IOoetzel K, Bueno AC, Queiroz R. Involvement rl the tracheobronchial tree in South American blastomycosis. Dis Chest 1963; 44:368-73 9 Lemle A, Wanke B, Mandel MB. Pulmonary localization rl paracoccidioidomycosis: lung function studies before and after treatment (in press) 10 Lemle A, Lima Neto JA, Mandel MB, Gaensler EA. South American blastomycosis: a treated case with conbollung function studies. Respiration 1974; 34:85-96 11 Lima Neto JA. Defici&ncia de alfa1-antitripsina na paracoccidioidomicose pulmonar (thesis~ Rio de Janeiro: lnstituto de 11siologia e Pneumologia, Univenidade Federal do Rio de Janeiro, 1979
'l1rls report demonstrates the development ofdyspnea and oxygen desaturation related to partial mechanical obstruc-tion of the left main-stem bronchus when the patient lay on his right side. We believe that these changes are due to the eft'ects ofgravity on the mass originating in the left upper lobe surgical stump. With the patient in the left lateral position, the mass was inferior or lower than the left main bronchus and would not affect its patency. In contrast, in the right lateral position, gravity caused the mass to protrude further into the airway of the left main-stem bronchus and thereby decrease ventilation to the left lower lobe. Conceivably, this led to hypoxemia based on low ventilation-perfusion matching in the left lower lobe. Because the patient's symptoms developed immediately upon turning onto his right side, we believe that the mechanism of the tachypnea and dyspnea was mechanical rather than related to desaturation. In patients with unilateral lung disease, such as atelectasis or pneumonia, inwlving either the right or left lung, Remolina and colleagues• noted that lower arterial oxygen tension occwred when the inwlved "sick" lung was dependent as opposed to the lateral position with the "good" lung dependent. Three of the nine patients had primary bronchogenic or metastatic carcinoma inwlving the lung. The authors postulated that these changes were due to ventilationperfusion mismatching associated with the gravitational inftuences on pulmonary blood flow. Our patient also had bronchogenic carcinoma, but there was no evidence of wlume loss or an alveolar &lling process on the chest roentgenogram. Fiberoptic bronchoscopic study demonstrated that partial mechanical obstruction contributed to his positional symptoms and oxygen desaturation rather than increased perfusion to dependent lungs with impaired ventilation. The information obtained in the investigation of our patient provided a physiologic understanding of his complaints and led to an early diagnosis prior to any radiologic changes. Localized radiation therapy was then instituted. Our results showed that oxygenation worsened when the patient was in the lateral position with his "good" or noninwlved lung dependent, and thus "up with the good lung" was most appropriate for his condition. Furthermore, this experience demonstrates the importance of careful interpretation of positional symptoms and physiologic alterations in such patients. REFERENCES
1 Blair E, Hickman JB. The eft'ect rlchange in body position on lung wlume and intrapulmonary gas mixing in normal subjects. J Clio Inwst 1955; 34:383-89 2 Robin ED, Hom B, Goris ML, Theodore J, Van Kessel A, Mazoub
J, et al. Detection, quantification, and pathophysiology rllung "spiders." 1rans Assoc Am Physicians 1975; 88:202-16 3 Robin ED, Laman D, Hom BR, Theodore J. Platypnea related to orthodeozia caused by true vascular lung shunts. N Engl J Med 1981; 294:941-43
4 &molina C, Khan AV, Santiago Tv, Edelman NH. Positional
hypoxemia in unilateral lung disease. N Eng! J Med 1981; 3«N:523-5 5 Fishman AP. Down with the good lung (Editorial~ N Engl J Med 1981; 3«N:537-38
Pulmonary Function In Paracoccldloldomycosls (South American Blastomycosis)* An Analysis of the Obstructive Defect Alfred Lsml., M.D.;t Bodo Wa..U, M.D.;:!: }014 U.boa Mnntla, M.D.;I Gullherme Loja Kropf, M.D.; Mor- Bernardo Mtmtld, M.D.,-J tmd StJmUei MantW, M.D .• Comparison or the mean results or routine pulmonary £unction studies or 17 patients with difl'use pulmonary paracoccidioidomyeosis (PM) and manifestations or chronic obstructive pulmonary disease (COPD) to those of 17 matebed patients with pure COPD sbowecl no signi&cant difl'ereoees. 1bese flnclinp were interpreted as fresh eviclence suggesting that apiratory obstruction in PM may be secondary to underlying COPD. Other eviclence to that
effect is discussed.
T
he lung is involved in almost all patients with paracoccidioidomycosis (PM~ one of the most important systemic mycoses in much of Latin America. There is usually a diffuse, polymorphic granulomatous pneumonitis, with in<rations, areas of consolidation, and occasional small-sized cavitation. Residual fibrotic streaking is common, particularly after treatment." Studies of pulmonary function most often show a predominantly obstructive defect, usually with hypoxemia of varying degree and mechanisms. ' 7 Since patients with PM are practically always mature male fiumhands who smoke, obstruction may be caused by underlying chronic obstructive pulmonary disease (COPD). This fact has not been generally considered, and care Cor patients with PM frequently consists exclusively of fungicidal treatment. Since nonsmoking patients with PM are exceedingly rare, we undertook to study the relative contribution of nonspeci&c obstruction due to COPD in patients with PM who have manifestations of COPD by comparing the pulmonary function of patients with PM who have manifestations of COPD (PMCOPD) to those of matched patients with pure COPD. MATERIALS AND METHODS
1be patients with PMCOPD were selected from a population rl34 parasitologically pi'OIIell cases consecutively seen at our laboratory. 1be patients with COPD were drawn from our &les. Selection was based on the possibiJity rl matching a pair rl patients from each group on the basis rl sa, age, the degrees rl dyspnea, clinical hyperinflation, and, on Inspiratory and expiratory x-ray studies, the decrease rl diaphragmatic motion and the presence rl air trapping. *From the Deparbnents rl Internal Medicine and Prewmtiw Medicine, the Federal Uniwrsity at Rio de Janeiro School rl Medicine, Rio de Janeiro, Brazil. tAssociate Pniessof rllntemal Medicine. :!:Assistant Professor rl PreYentiw Medicine. IM~logist Research Institute, Uniwnidacle Cama Filho. UStri&' An~logist, Conemmaugb Valley Memorial Hospital, . Johnstown. Pa. fChie£ Department rl Anesthesia, Medical Center rl Macon, Macon, Ca. &print ~: Dr. LsmJ., RUG FatJ.l FatJ.l 20, ap l«JJ, Rio d. jaf!No, R.]., Bnml22430 CHEST I 83 I 5 I MAY, 1883
127
Smoldng habits were the same in seven pairs, the patient with PMCOPD smoked slightly more in two, and the patient with COPD smoked more in seven. In one, infOrmation was not euct (total, 17 pairs).
Spirometric studies were perfOrmed on a 9-L water spirometer coupled to a helium analyzing catharometer (Pulmonet; Godart). Samples rl arterial blood and expired air were analyzed lOr respiratory gases and pH on the Clark and Severingbaus electrodes according to previously discussed methods. • The &actional uptake rl carbon monoxide (FCO). calculated as the &action rlinspired carbon monoxide minus the &action rl expired carbon monoxide divided by the &action rl inspired carbon monoxide times 100, was determined with a commercially available apparatus (Diffusiontest; Godart) which measures the diffusing capacity by the steady-state end-tidal sampling method. REsui.IS
The patients with PMCOPD had a slightly higher mean furced expiratory volume in one second over the ratio ~the vital capacity (FEV1NC; 51.8±15.2 percent vs 46.8±16. 7 percent~ predicted), a lower mean VC (83.8 ± 20.2 percent vs 93.2±30.1 percent) and a slightly lower mean residual volume (RV; 171.7±56.4 percent vs 197.3±59.3 percent) than their counterparts with COPD; howeve~; none of these differences was significant at the 5 percent level. The FEV./VC was higher in the patient with PMCOPD in 11 pairs and in the patient with COPD in one pail; and was equal in five pairs. The VC was larger in the patient with PMCOPD in six pairs and in the patient with COPD in seven, and was equal in fuur pairs. The RY, available lOr 13 pairs, was larger in the patient with PMCOPD in fuur pairs and in the patient with COPD in eight pairs, and was equal in one pair. Because ~ missing data points, gas transfer parameten were confronted by a simple comparison of means, in a nonmatched fashion. Mean resting arterial oxygen tension (PaO.), available in 15 patients with PMCOPD and five patients with COPD, was 76.8±14.1 mm Hg and 77.2±3.1 mm Hg, respectively. Mean Pa01 after breathing pure oxygen, available in 13 patients with PMCOPD and five patients with COPD, was 528.7 ± 76.5 mm Hg and 560.0±44.7 mm Hg, respectively. Mean FCO, available in fuur patients in each group, was 46.7±6.8 percent fur the patients with PMCOPD and 47.5±4.4 percent fur the patients with COPD. None ~the differences between these means was significant at the 5 percent level. DISCUSSION
The absence of significant differences between the means the results of pulmonary function tests of patients with PMCOPD and with COPD suggests that the changes in the group with PMCOPD may be due to underlying obstruction rather than to the coexisting in6ltrates. One may speculate that ifthe mycotic inftammation had a considerable impact on function, the results in the patients with PMCOPD should be different from those of comparable patients with COPD. These findings agree with conclusions tentatively drawn from other evidence, namely the lack of endoscopic' or pathologicl data showing mycotic bronchial lesions capable of ~
828
causing manifestations ofCOPD. Autopsies are rare because patients are usually lost to fullow-up, as they return to their villages after therapy. In one ~our few autopsied cases, that ~ a treated man with diffuse fibrosis on the x-ray 6lm, bronchi were carefully studied down to the terminal bronchioli, and only typical nonspecific lesions of chronic bronchitis were fuund. Tests ~ pulmonary function befOre and after specific treatment"-111 show no consistent change in obstruction, even with significant radiologic clearing. The decisive data would, ~course, be fuund in the study of nonsmoking patients free ~COPD. These are very rare. In the literature, conelation functional changes to the smoking status in PM has not been reported regularly by othen. The only nonsmoking patient in our series (also the only woman) had a normal spirogram (VC of 3,280 ml, 107 percent of predicted, and FEV1 of2,430 ml, 75 percent ~VC). The only evidence fur a relationship between PM and COPD comes from Lima Neto, u who fuund that basilar bullae may be prominent and may develop rapidly in patients some special with PMCOPD, suggesting the presence~ emphysema-fOrming mechanism in PM.
m
REFERENCES 1 Fialho AS. Localiza9"\es pulmonares de micose de Lutz: anatomia patolcSgica e patogenia (thesis). Rio de Janeiro: Faculdade
Nacional de Medicina da Universidade do Brasil, 1946 2 Saltelder K, Doehnert G, Doehnert HR. Paracoccidioidomycosis: anatomic study with complete autopsies. Virchow's Arch (Pathol Anat) 1969; 348:51-76 3 Machado Filho J; Lisboa Miranda J. Conside~s relativas l blastomicose sui-americana: da ~ pulmonar entre 338 casos consecutiws. Hospital1960; 58:431-49 4 Hestrepo A, Bobledo M, Guti6rrez F. Sanclemente M, Casta6eda E, Gallo G. Paracoccidioidomycosis (South American blastomycosis): a study rl39 cases observed in Medellin, Colombia. Am J 'liop Med Hyg 1970; 19:68-76 5 Londero AT. The lung in paracoccidioidomycosis. In: Panlcoocidioidomycosis (PHO scienti&c publication 254~ \\Uhington, DC, Pan American Health Organization, 1972;109-17 6 Lemle A, Vieira LOBO, Milward GAF, Lisboa Miranda J. Lung function studies in pulmonary South American blastomycosis: correlation with clinical and roentgenologic findings. Am J Mecl 1970; 48:434-72 7 AfOnso JE, Nery LE, Bomaldini H, Bogossian M, RibeiroRatto a Fun~ pulmonar na paracoccidioidomicose (bJasto. micose sui-americana~ 8ev Inst Med li"Op Slo Paulo 1979; 21:269-80 8 IOoetzel K, Bueno AC, Queiroz R. Involvement rl the tracheobronchial tree in South American blastomycosis. Dis Chest 1963; 44:368-73 9 Lemle A, Wanke B, Mandel MB. Pulmonary localization rl paracoccidioidomycosis: lung function studies before and after treatment (in press) 10 Lemle A, Lima Neto JA, Mandel MB, Gaensler EA. South American blastomycosis: a treated case with conbollung function studies. Respiration 1974; 34:85-96 11 Lima Neto JA. Defici&ncia de alfa1-antitripsina na paracoccidioidomicose pulmonar (thesis~ Rio de Janeiro: lnstituto de 11siologia e Pneumologia, Univenidade Federal do Rio de Janeiro, 1979