The Roentgen Diagnosis of Fungous Infections of the Lungs with Special Reference to Coccidioidomycosis

The purpose of the present paper is to reconsider the roentgen manifestations of coccidioidal infection of the lungs, and to attempt comparisons with diseases, mycotic and otherwise, which may simulate it. Conceptions of the disease have been revolutionized by the proof, by Dickson, that primary pulmonary coccidioidomycosis is a spontaneously recovering disease, widespread in the San Joaquin Valley of California, and by further studies of its behavior, clinical, pathological, and epidemiologica1. Cases have accumulated since our previous reports (2–4) confirming some impressions, modifying and correcting others. The clinical, mycologic, pathologic, allergic, and epidemiologic aspects of the disease will be discussed only as they appear necessary to a roentgenologic presentation. These topics are covered elsewhere in this symposium and in the literature. Some recent studies of importance may be mentioned. Primary coccidioidomycosis has been described by Dickson and associates (6, 7, 8, 9, 11); its epidemiological features, by Smith (22); sensitivity tests, by Kessel (17), Stewart and Kimura (23), and Thorner (24); therapy, particularly immunotherapy, by Jacobson (16). Many cases are required to type a disease, roentgenologically as well as otherwise. Even then unusual and confusing manifestations arise. Although primary coccidioidomycosis is widespread in its restricted location, cases studied roentgenographically are relatively few. In the comparatively infrequent secondary form, the number of cases is still inadequate. Our own series of this stage, probably larger than can be assembled in anyone institution, may establish clear predilections, and illustrate most manifestations likely to be encountered. It is inadequate for close differentiation, and particularly to establish roentgenologic grounds for proof or elimination of the disease. The positive diagnosis still rests mainly upon the identification of Coccidioides immitis. Primary Coccidioidomycosis It has been known for many years that the initial infection is far most commonly pulmonary, and that this need not lead to the generalized disease. In 1930 we saw the films of two such cases, through the courtesy of Dr. Philip Pierson. Prior to the identification of valley fever, the tendency was to attribute the few recoveries which were observed to early recognition and treatment. Chamberlain, however, in discussion in 1930, said: “I suspect that cases occur with rapid recovery, without identification of the organism” (2). A clear history of the frank influenza- or pneumonia-like primary attack and roentgenograms are available for only a small proportion of those reacting positively to the coccidioidin vaccine. Roentgenographic series will be heavily weighted with patients whose respiratory attacks have been clinically severe, or who have had an erythema nodosum.