What is the role of biopsy in the workup of coccidioidomycosis?

Updated: Aug 27, 2019
  • Author: Duane R Hospenthal, MD, PhD, FACP, FIDSA, FASTMH; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

Peripheral solitary pulmonary nodules secondary to coccidiomycosis are especially amenable to diagnosis by percutaneous transthoracic needle biopsy. Most percutaneous transthoracic needle biopsies are CT guided, which allows direct visualization of the needle into the lesion. Specimen fungal stains demonstrating spherules or culture growing C immitis are diagnostic. Cytology of the specimen should be obtained to rule out malignancy.

Closed pleural biopsy may be diagnostic in patients with coccidioidal pleural effusions. Identification of spherules infiltrating the pleural is diagnostic. Culture of pleural biopsy specimens has the highest yield, with isolation of C immitis of in all cases in one small series. The typical pleural effusion is exudative and lymphocytic with modest eosinophilia. Pleural fluid cultures have a low yield, with isolation of C immitis in less than 20% of patients.

Surgical biopsy may be required if the diagnosis cannot be established using the aforementioned approaches. Surgical biopsy is best suited for sampling lymph nodes or parenchymal lung disease. Cervical mediastinoscopy can access most mediastinal lymph nodes and video-assisted thoracoscopy can be used to obtain parenchymal lung tissue.

In extrapulmonary coccidiomycosis, fine-needle aspiration provides a quick and less invasive diagnosis if easily accessible subcutaneous lymph nodes are noted on examination. [63]

Synovial biopsy may be needed to document coccidioidal dissemination to a joint.


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