A 46-year-old man comes to the physician for follow-up. He recently went to the emergency department after fracturing 2 ribs in a bicycle accident. During the evaluation, a CT scan of the chest revealed an 8-mm pulmonary nodule. He has experienced no cough, dyspnea, fevers, chills, or weight loss. The patient lives in Indiana and works in the agriculture industry. He is a current smoker with a 25-pack-year history. He underwent a bronchoscopic biopsy of the nodule, which revealed budding yeast. Bacterial and fungal culture from the biopsy yielded no growth.
Which is the most appropriate treatment for this patient's nodule?

Question

A 46-year-old man comes to the physician for follow-up.  He recently went to the emergency department after fracturing 2 ribs in a bicycle accident.  During the evaluation, a CT scan of the chest revealed an 8-mm pulmonary nodule.  He has experienced no cough, dyspnea, fevers, chills, or weight loss.  The patient lives in Indiana and works in the agriculture industry.  He is a current smoker with a 25-pack-year history.  He underwent a bronchoscopic biopsy of the nodule, which revealed budding yeast.  Bacterial and fungal culture from the biopsy yielded no growth.
Which is the most appropriate treatment for this patient's nodule?

Quizplus · Accepted Answer

11ec193a_9865_ab91_853d_d9cc93647e9c_MD0002_00 This patient has an asymptomatic pulmonary nodule with budding yeast on microscopic inspection, and has epidemiology suggestive of histoplasmosis. Acute histoplasmosis should be considered in patients who travel to or reside in endemic areas (Ohio or Mississippi River valleys) and have a febrile illness with respiratory symptoms and compatible imaging. In particular, it should be suspected in patients who have a pulmonary infection that does not respond to usual antimicrobial therapy. Following an initial infection, residual nodules or histoplasmomas may persist, though patients can be asymptomatic. There is no evidence that antifungal therapy has any impact on these nodules and treatment is not recommended. Ohio or Mississippi River valleys (Choice A) The treatments of choice in the management of acute, diffuse symptomatic pulmonary histoplasmosis are amphotericin B or azoles such as itraconazole or fluconazole. However, asymptomatic pulmonary nodules secondary to histoplasmosis do not benefit from systemic antifungal treatment. (Choice B) Echinocandins such as caspofungin do not have reliable activity against Histoplasma capsulatum. (Choice D) Surgical removal may be indicated for histoplasmomas causing mass effect on local structures such as bronchi. Surgical removal is not necessary in an asymptomatic individual. (Choice E) Although frequently used in the management of disseminated fungal infections, voriconazole is not recommended for the management of acute histoplasmosis as resistance may develop with treatment. Antifungal therapy is not recommended for treatment of an asymptomatic pulmonary nodule caused by H capsulatum. Educational objective: Histoplasmosis can present as an asymptomatic pulmonary nodule in patients living in endogenous areas (the Ohio and Mississippi River valleys). These patients do not require antifungal therapy if they are not immunocompromised. __________ References: Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/17806045) Histoplasmosis. (http://www.ncbi.nlm.nih.gov/pubmed/12751258)

A 46-Year-Old Man Comes to the Physician for Follow-Up