Surgery in primary pulmonary coccidioidomycosis and in the combined diseases of coccidioidomycosis and tuberculosis.

S urgical treatment of coccidioidomycosis is recognized as a proved method of curative therapy. However, there is not universal agreement as to the specific method of management. The decision regarding management is made on personal experience and judgment and this varies with the individual surgeon. In general, the division on methodology hinges on an opinion regarding administration of amphotericin B (Fungizone). There are those surgeons who do not use it in any circumstance. Some reluctantly agree that it may have a place for treatment of complications. The latter insist their complications are few and their use of amphotericin B is therefore minimal. They believe amphotericin B is an extra hazard to surgical therapy. A second group of surgeons uses amphotericin B in specific circumstances, but prefers to avoid its use if at all possible. The third group, and the one to which the authors adhere, believe that amphotericin B has a definite place in surgical methodology. The specifics for its use have been detailed in other publications, but reference to a suggested dosage of this drug will be made later in the paper. The justification for its use is based on the demonstrated decrease in complications when two groups of surgical cases are compared. In one group, surgery was performed without amphotericin B; the other group received amphotericm B. The complication rate decreased from 20.4 per cent to 4.2 per cent.1 It has been of significant importance to us to have support in our opinion and conclusions from a separate parallel unrelated study. Evans and the late Dr. William Winn reached identical conclusions as to the merits of amphotericin B. This was summarized in a statement by Dr. Winn, “the judicious use of amphotericin B in preparing caytary coccidioidomycosis for surgery is of enough protection in safeguarding surgical results as to far outweigh any objections that might be raised as to amphotericin B toxicity.”2 A similar difference of opinion regarding the use of amphotericin B in the surgical treatment of histoplasmosis has been recorded. Support for the value of amphotericin B in this disease will be found in articles by Beatty,3 Furcolow,4 Gryboski5 and their co-workers. Ahn et al#{176} have recently reported their experiences in surgical therapy of caytary pulmonary histoplasmosis. They recommended both preoperative and postoperative use of amphotericin B because of a remarkable reduction of complications of the surgery when this regimen is followed. Levene and colleagues7 give lukewarm but obvious support of its use, but fail to mention dosage used. The non-advocates of amphotericin B are Diveley,8’9 and Mendenhall and Sealy.1#{176}It would seem, therefore, that the neophyte in this field, whether concerned with coccidioidomycosis or histoplasmosis, will be torn between fact, opinion, experience, medical and surgical contacts and personal judgment. All this is further influenced by the geographic location of the practice. It should be emphasized that amphotericin B is not recommended for every case of pulmonary coccidioidomycosis coming to surgery. Until we know a good deal more about this disease, we cannot make any statement as to why certain cases of pulmonary coccidioidomycosis are tame and somnolent and not given to causing trouble. The solid nodule is one of the latter lesions. Other lesions (cavities in particular) are wild, dangerous, capricious and unpredictable. We can only emphasize that in the latter case, which we try to identify herein, amphotericin B is often obligatory. It is most important to identify the cavitary “fissure jumper.” This type cavitary lesion is recognized by those experienced in this disease. The “why” of transgression of both visceral and parietal pleural boundaries remains a mystery. Tuberculosis does not act in a like manner. The indications for surgical therapy of pulmonary coccidioidomycosis are listed in Table 1. The pulmonary coin lesion requires special attention. Coccidioidomycosis as a geographic endemic