THORACOTOMY FOR PULMONARY MYCOSES IN NON-HIV-IMMUNOSUPPRESSED PATIENTS

Pulmonary mycoses can be life threatening in patients who are in an im munocompromised state stemming from defective host defenses or the use of certain treatment regimens. In 36 immunosuppressed patients underg oing thoracotomy for the treatment of pulmonary fungal disease, the un derlying cause of immunosuppression was malignancy (n = 9), Wegener's granulomatosis (n = 4), hematologic disorders (aplastic anemia, 5-Q mi nus syndrome, or myelofibrosis) (n = 6), or chronic granulomatous dise ase of childhood (n = 17). The mean age of the patients was 25 years, and 89% were symptomatic (fever, n = 27; cough, n = 20; chest pain, n = 14; and other, n = 13%. Chest x-ray studies revealed the presence of cavitary disease (n = 7), a mass (n = 8), infiltrates (n = 20), or ca vity and infiltrate (n = 1). A preoperative diagnosis was lacking in 2 3 of the 36 patients. Procedures included wedge biopsy (n = 13), segme ntectomy with or without wedge or chest wall resection (n = 5), lobect omy with or without chest wall resection (n = 16), wedge resection plu s completion pneumonectomy (n = 1), and segmentectomy plus completion pneumonectomy (n = 1). Fungi identified included Aspergillus (n = 23), Zygomycetes (n = 4), Cryptococcus (n = 3), and other (n = 6; 1 each), and specific antifungal treatment was instituted in 34 of the patient s (94%). The 31% operative tie, <30-day or inhospital) mortality was c hiefly due to multiorgan system failure (9/11). Univariate analysis id entified the following as prognostic of death during hospitalization: underlying hematologic disease (p(2) = 0.012), angioinvasive disease ( p(2) = 0.0064), treatment with chemotherapy and steroids (p(2) = 0.052 ), and a granulocyte percentage of 30% or less or a granulocyte count of 100 or less (p(2) = 0.048). Moreover, multivariate analysis reveale d that angioinvasion correlated with all risk factors and operative mo rtality. Nineteen patients are still alive at a mean follow-up period of 2.8 years. These data reinforce the risk of operation for the treat ment or diagnosis of angioinvasive fungal disease in selected groups o f immunosuppressed patients, and the need for improved pharmacologic a gents in these high-risk populations.