Correspondence

The Solitary Pulmonary Nodule

N Engl J Med 2003; 349:1575October 16, 2003

Article

To the Editor:

In their Clinical Practice article, Ost and colleagues (June 19 issue)1 do not specifically address coccidioidomycosis. In areas where this disease is endemic, the percentage of pulmonary nodules due to coccidioidomycosis is nearly 30 percent.2 Many such nodules are noncalcified and larger than 3 cm in diameter, suggesting that such patients are at high risk for neoplasm. In most cases, the results of coccidioidal serologic tests are negative and imaging techniques are unhelpful, leading to the use of invasive techniques to establish the diagnosis. Fine-needle aspiration is diagnostic in only about 50 percent of cases of coccidioidal nodules.2,3 Surgical biopsy results in higher yields but is associated with increased complications. Until more sensitive tests are available, determining whether there is a history of coccidioidal pneumonia and performing coccidioidal serologic testing might allow radiographic follow-up, rather than invasive testing. Informing patients with primary coccidioidal pneumonia that they may subsequently be found to have a pulmonary nodule may also be helpful.

Neil M. Ampel, M.D.
University of Arizona, Tucson, AZ 85723

3 References

1
Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. N Engl J Med 2003;348:2535-2542
Full Text | Web of Science | Medline

2
Forseth J, Rohwedder JJ, Levine BE, Saubolle MA. Experience with needle biopsy for coccidioidal lung nodules. Arch Intern Med 1986;146:319-320
CrossRef | Web of Science | Medline

3
Chitkara YK. Evaluation of cultures of percutaneous core needle biopsy specimens in the diagnosis of pulmonary nodules. Am J Clin Pathol 1997;107:224-228
Web of Science | Medline

Author/Editor Response

We appreciate Dr. Ampel's insight and concur that physicians need to take into consideration local endemic fungi as potential contributors to the differential diagnosis. Assessing the base-line probability of fungal infection as a cause of nodules is difficult. Although in many series a high percentage of cases is due to fungal disease, the denominator varies according to the method of case finding. Both of the cited series (by Chitkara1 and by Forseth et al.2) were retrospective case series of fine-needle biopsies. These particular studies do not give the probability of coccidioidomycosis in all patients presenting with nodules but, rather, the probability of coccidioidomycosis given that a physician believes there is enough uncertainty to warrant a needle biopsy. In the study by Chitkara, 97 percent of the nodules deemed probably malignant by radiologists were positive for cancer, whereas 39 percent of the “indeterminate” nodules were malignant. The cases of coccidioidomycosis in this series were found primarily in the latter group.

Although the true prevalence of coccidioidomycosis as a cause of nodules is uncertain, we agree with Dr. Ampel that physicians should consider the probability of this condition when deciding on a management strategy.

David Ost, M.D.
Alan M. Fein, M.D.
Steven H. Feinsilver, M.D.
North Shore University Hospital, Manhasset, NY 11030
dost@nshs.edu

2 References

1
Chitkara YK. Evaluation of cultures of percutaneous core needle biopsy specimens in the diagnosis of pulmonary nodules. Am J Clin Pathol 1997;107:224-228
Web of Science | Medline

2
Forseth J, Rohwedder JJ, Levine BE, Saubolle MA. Experience with needle biopsy for coccidioidal lung nodules. Arch Intern Med 1986;146:319-320
CrossRef | Web of Science | Medline

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