Pulmonary Intracavitary Fungus Ball

In the maze of diseases attributable to or associated with fungous infections, none are more controversial than bronchopulmonary moniliasis and aspergillosis. Despite numerous discussions of the clinical, pathologic, and mycologic features of these conditions, considerable variance of opinion persists concerning criteria for establishing their diagnosis. Even the pathogenicity of Aspergillus and Candida is subject to dispute. Nevertheless, these fungi in their usual saprophytic state produce a pulmonary lesion with a distinctive radiologic picture, namely, the pulmonary intracavitary fungus ball. As the designation implies, the essential feature is a ball of mycelia lying free in a pulmonary cavity which communicates with the bronchial tree. According to Monod (7), Dévé described the first case in 1938, and called the process “megamyce-tome intrabronchiectasique.” In the ensuing years 23 additional cases have been reported under various appellations, with histologic confirmation in 15 (Table 1). In those instances in which sufficient data were included, it was evident that the clinical, radiologic, and pathologic features conformed to a characteristic pattern. Four additional cases, 3 of which were proved, are presented here, in the belief that they amplify and supplement knowledge of this disease. Case Reports Case I: An 82-year-old man was admitted to the Cincinnati General Hospital on July 6, 1952. He appeared chronically ill and dehydrated but complained only of weakness and dyspnea on exertion. The physical examination was normal except for the presence of a Blumer's shelf. The sputum was negative for acid-fast bacilli. Roentgen Findings: An upper gastrointestinal examination demonstrated a large carcinoma of the stomach. Postero-anterior and lateral teleroentgenograms of the chest (Figs. 1 A and B) showed the right upper lobe to be moderately decreased in volume and almost completely excavated. Lying transversely in the base of the thin-walled cavity was a smooth ovoid mass measuring 3.5 × 2.5 cm. in diameter. Three days later a repeat examination (Fig. 1C) revealed a slight shift in the position of the mass. The patient died suddenly on July 15, 1952. At autopsy many dense pleural adhesions were found over the right upper lobe, which was almost completely cavitated. The walls of the cavity were epithelialized and trabeculated. In its dependent portion was a free body, brown in color and soft in consistency, measuring 3×2×2 cm. Microscopy showed extensive fibrosis and anthracotic pigment along with collections of lymphocytes and plasma cells in the lung adjacent to the cavity, but there was no evidence of fungi, active tuberculosis, or neoplasm. The cavity wall was composed of dense connective tissue containing inflammatory cells.