Numerous malignancies and infectious etiologies cause cavity formation but rarely does the process involve an entire lung. We describe progressive right lung cavitary destruction requiring management with repetitive fiberoptic bronchoscopy (FOB).
A 60 year old male presented in September 1998 with cough and pleuritic chest pain. Medical history was significant for traumatic right rib fractures with pneumothorax and 40 pack year smoking history. Radiography demonstrated a right upper lobe (RUL) infiltrate and left exudative pleural effusion. After antibiotic therapy, repeat evaluation revealed persistent RUL infiltrate with pleural thickening and interval resolution of the effusion. Fiberoptic bronchoscopy was performed; stains and cultures were negative for infection. Skin testing with purified protein derivative was negative. He was referred to our institution in November 1998 with increasing chest pain, non-productive cough and weight loss. Chest computed tomography (CT) showed an increasing RUL infiltrate, pericardial effusion and extensive mediastinal and cervical adenopathy. Mediastinal exploration, pericardial window with biopsy, and right apical lung biopsy were performed; all were negative for malignancy or infection. The lung pathology was described as “diffuse interstitial fibrosis with emphysematous changes, atelectasis, and parenchymal hemorrhage suggestive of desquamative interstitial pneumonia.” The patient was returned to the referring hospital but failed to follow-up.At another facility in July 2001, a right thoracotomy was attempted for the persistent RUL infiltrate, but was aborted due to chest wall adhesions and excessive bleeding. He later developed hemoptysis, but had a nondiagnostic FOB in March 2002. The patient returned in November 2002 with progressive symptoms and cutaneous “bubble-like” lesions with respiratory variations at the thoracostomy site. Chest CT demonstrated progressive change with complete destruction of right upper and mid lung parenchyma and minimal intact basilar parenchyma. Centrilobular nodules along with diffuse pleural thickening were noted bilaterally. Fiberoptic bronchoscopy demonstrated thick secretions and right lung airway erythema with normal left anatomy. Histoplasmosis capsulatum was isolated from left upper lobe and tracheal aspirates, but biopsies had no granulomatous changes. He began oral itraconazole for chronic pulmonary histoplasmosis with stabilization of CT findings during regular evaluations.In August 2004, he was admitted with interval development of a right lung air/fluid level and draining cutaneous fistula from the prior thoracostomy site (Figure 1). Chest CT showed complete right lung destruction, a large bulla with air/fluid level, and chest wall erosion with fistula formation. Bronchoscopy revealed the right bronchus intermedius opened into a large cavity with purulent secretions and fibrous tissue (Figure 2). All right upper and lower lobe airways terminated into the cavity. After aspiration of 800 ml of secretions, the cutaneous fistula opening was identified and later spontaneously closed. For the next six months, the patient required regular repeat FOB to aspirate secretions while gaining weight to tolerate definitive thoracotomy.
Cavitary lung disease due to Histoplasma capsulatum is well recognized, but complete destruction of the lung parenchyma is rarely reported1. Cavitary histoplasmosis is more common in men and those patients with underlying emphysema. Successful treatment of cavitary histoplasmosis to preserve viable lung was reported in 29 patients2. Despite early evaluation in this case, the right lung was completely destroyed. More importantly, FOB became a necessary adjunct to drain infected secretions from the destroyed lung until definitive surgery.
Development of this large chest cavity secondary to histoplasmosis was treated by repeated FOB until definitive thoracotomy to obliterate the infected space.
Jennifer Rippon, None.