An Unusual Presentation of Blastomycosis.

INTRODUCTION: Blastomycosis is a rare pyogranulomatous infection that most commonly involves the lungs and sometimes the skin. Other manifestations are much less common. Diagnosis relies on biopsy, histopathology, and culture of suspicious lesions. CASE PRESENTATION: In this case, a healthy 42-year-old male from Wisconsin presented to the emergency department with a chief complaint of 2 weeks of knee pain without a clear mechanism of injury. Upon further examination, he was found to have lesions on his abdomen, which he had first noticed over 3 years prior and had been treated with antibiotics as cellulitis for nearly 18 months. Biopsy of these lesions was consistent with blastomycosis infection, and further work-up and examination was notable for brain and laryngeal lesions without any pulmonary involvement. Intense anti-fungal treatment was immediately initiated with dramatic improvement in his symptoms. DISCUSSION: This case highlights the importance of a thorough physical exam and consideration of rare infections in cases without clear answers. To our knowledge, this is the first published example of a blastomycosis infection involving brain, laryngeal, skin, and knee lesions without pulmonary infection.

A case series and literature review of blastomycosis during pregnancy amidst the COVID-19 crisis.

Blastomycosis dermatitidis is a rare fungus known for is classic mimicry of pneumonia, lung cancer, and mycobacterial infections. Whilst it is known best for affecting those in the Ohio and Mississippi River basins, several cases have erupted in the Midwest region. Few case reports have focused on blastomycosis and its sequalae in pregnancy. We present a case series of blastomycosis diagnosed during the second and third trimesters in two women amidst the COVID-19 pandemic. Given immunosuppression, complications and treatment can be challenging for clinicians. This case series and discussion hopes to provide future clinicians with the presentation, diagnosis, management, and treatment of this uncommon infection.

Endemic Systemic Mycoses in Italy: A Systematic Review of Literature and a Practical Update.

Endemic systemic mycoses such as blastomycosis, coccidioidomycosis, histoplasmosis, talaromycosis, paracoccidioidomycosis are emerging as an important cause of morbidity and mortality worldwide. We conducted a systematic review on endemic systemic mycoses reported in Italy from 1914 to nowadays. We found out: 105 cases of histoplasmosis, 15 of paracoccidioidomycosis, 10 of coccidioidomycosis, 10 of blastomycosis and 3 of talaromycosis. Most cases have been reported in returning travelers and expatriates or immigrants. Thirtytwo patients did not have a story of traveling to an endemic area. Fortysix subjects had HIV/AIDS. Immunosuppression was the major risk factor for getting these infections and for severe outcomes. We provided an overview on microbiological characteristics and clinical management principles of systemic endemic mycoses with a focus on the cases reported in Italy.

First Japanese case of disseminated blastomycosis imported from North America: A case report.

Blastomycosis is a fungal infectious disease that can occur in both immunocompromised and immunocompetent populations endemic in North America, with no previous reports in Japan. A 26-year-old Japanese female patient with no relevant medical history presented intermittent left back pain and an abnormal shadow in the left upper lung field eight months ago at a local clinic. She was referred to our hospital for further evaluation and treatment. The patient currently lives in Japan, but until two years ago had spent several years in New York, Vermont and California. Chest computed tomography revealed a 30 mm mass with a cavity in the left pulmonary apex. The specimens obtained by transbronchial biopsy showed periodic acid-Schiff stain (PAS)-positive and Grocott-positive yeast-like fungi scattered among the granulomas, with no malignant findings, and the initial pathology did not lead to a definitive diagnosis. She was empirically started on fluconazole because of onset of multiple subcutaneous abscesses and was referred to the Medical Mycology Research Center. Although antibody tests could not diagnose the disease, blastomycosis was suspected based on the pathology of the skin and lung tissue at the Medical Mycology Research Center, and Blastomyces dermatitidis was identified by ITS analysis of the rRNA region. Her symptoms and CT findings gradually improved with fluconazole. We reported the first Japanese case of blastomycosis with pulmonary and cutaneous involvement in Japan. As the number of overseas travelers is expected to continue increasing, we would like to emphasize the importance of travel history interviews and information of blastomycosis.

Disseminated Blastomycosis in an African American immunocompetent pediatric patient: Lessons learned.

Disseminated blastomycosis can be challenging to diagnose given possible involvement of nearly any extrapulmonary organ system and the limitations of fungal diagnostic testing. Certain racial groups are at increased risk of disseminated fungal infections, even in immunocompetent patients. We describe a case of disseminated blastomycosis with cutaneous involvement in an African American adolescent with delayed diagnosis. Dermatologists can play an important role in the timely diagnosis of this disease entity by performing appropriate cutaneous biopsy techniques and should be involved early in these cases.

Disseminated Blastomycosis Mimicking Metastatic Head and Neck Cancer in a 70-year-Old Man.

Blastomycosis is a fungal infection known to mimic many disease processes, including malignancy. A 70-year-old man presented with an enlarging neck mass and, incidentally found on preliminary imaging, a lung mass. The initial biopsy of the neck mass demonstrating cytologic atypia and mitotic figures was suggestive of malignancy. Whole body positron emission tomography (PET)/CT revealed hypermetabolic lesions in multiple sites, including the neck, lung, and soft tissue, raising concern for metastatic disease. Repeat sampling from multiple lesions, however, demonstrated granuloma. Microbiological studies were collected, and Blastomyces dermatitidis was isolated in culture. The diagnosis of disseminated blastomycosis was made, and the patient received antifungal therapy with good response. A high degree of suspicion for blastomycosis in endemic areas is required to ensure patients receive appropriate and timely treatment. Laryngoscope, 133:2237-2239, 2023.

Fungal Lesions of the Oral Mucosa Diagnosis and Management.

Oral fungal infections are opportunistic and due to impaired host resistance. The increasing number of immunosuppressed individuals contributes to rising numbers of mycoses worldwide, and the ease of global migration has allowed the geographic range of endemic mycoses to expand. Deep fungal infections can clinically mimic other pathologic conditions including malignancy. This review highlights the pathogenesis, clinical features, diagnosis, and treatment recommendations of eight fungal infections that can be encountered in the dental setting.

Blastomycosis-like pyoderma: A pitfall for the misdiagnosis of squamous cell carcinoma.

Blastomycosis-like pyoderma is a rare cutaneous disease presenting as solitary or multiple verrucous or ulcerated plaques and nodules in a susceptible patient. The diagnostic criteria include characteristic verrucous plaques with pustules and elevated borders, histopathologic findings of pseudoepitheliomatous hyperplasia with abscesses, growth of at least one bacterium in tissue culture, and exclusion of other infectious sources. This report describes a case of a 62-year-old man with poorly controlled type 2 diabetes mellitus who presented with plaques, nodules, and ulcers in both groins and the right ankle. The patient was initially misdiagnosed with multiple squamous cell carcinomas and underwent several operations. A review of the pathology slides revealed pseudoepitheliomatous hyperplasia with multiple dermal abscesses, while repeated wound and tissue cultures were positive for coagulase-negative Staphylococcus. Blastomycosis-like pyoderma was diagnosed. The patient was subsequently treated with culture-guided prolonged antibiotic therapy followed by intralesional steroid injection, which led to gradual resolution of the lesions.

Disseminated blastomycosis in a 1-year-old, male golden retriever-poodle crossbred dog.

A 1-year-old male golden retriever-poodle crossbred dog was brought to a veterinary clinic with a 1-month travel history to Muskoka, Ontario and a 1-week history of left eye irritation and ocular discharge. Ophthalmic examination and blood analysis revealed bilateral uveitis with a normal complete blood (cell) count and biochemistry panel. Symptomatic treatment was administered with no improvement observed and the dog returned 2 weeks later for assessment of a draining swelling of the left hind 4th digit. Clinical examination of thoracic radiographs and abdominal ultrasound showed evidence of disseminated blastomycosis characterized by pulmonary lesions, and multifocal lymphadenopathy. Biopsy of the draining lesion and cytological examination of an enlarged lymph node established diagnosis. The dog was started on a standard antifungal treatment protocol (itraconazole) but returned after 11 d of treatment with neurological signs including ataxia, paraparesis, left head tilt, and compulsive turning. Humane euthanasia was chosen and the diagnosis was confirmed at postmortem examination.

Blastomycose disséminée chez un chien croisé golden retriever-caniche mâle de 1 an. Un chien croisé golden retriever-caniche mâle âgé d'un an a été amené à une clinique vétérinaire avec un historique de voyage d'un mois à Muskoka, en Ontario et une histoire d'irritation de l'oeil gauche et d'écoulement oculaire d'une semaine. L'examen ophtalmologique et l'analyse sanguine ont révélé une uvéite bilatérale avec une numération globulaire complète et un bilan biochimique normaux. Un traitement symptomatique a été administré sans amélioration observée et le chien est revenu 2 semaines plus tard pour l'évaluation d'une enflure drainante du 4e doigt postérieur gauche. L'examen clinique des radiographies thoraciques et de l'échographie abdominale a montré des signes de blastomycose disséminée caractérisée par des lésions pulmonaires et une lymphadénopathie multifocale. Une biopsie de la lésion drainante et un examen cytologique d'un noeud lymphatique augmenté de volume ont permis d'établir le diagnostic. Le chien a débuté un protocole de traitement antifongique standard (itraconazole) mais est revenu après 11 jours de traitement avec des signes neurologiques, notamment ataxie, paraparésie, inclinaison de la tête à gauche et tournis compulsif. L'euthanasie sans cruauté a été choisie et le diagnostic a été confirmé lors de l'autopsie.(Traduit par Dr Serge Messier).

Mandibular Blastomycosis in a 5-Year-Old Dog.

A case of localized oral mandibular blastomycosis is described in a five-year-old dog. Complete resolution of clinical signs and oral radiographic changes were seen following itraconazole therapy at 5 mg/kg/day for four and a half months. The patient remained free of Blastomyces at the one year follow up based on the Mira Vista Blastomyces urine antigen test by EIA (Enzyme Immunoassay)a. A literature review of localized blastomycosis cases in humans and dogs was performed, available diagnostic tests evaluated, and treatment comparisons made.

A rare presentation of blastomycosis as a multi-focal infection involving the spine, pleura, lungs, and psoas muscles in a Saudi male patient: a case report.

BACKGROUND: Blastomycosis is a disease caused by the fungus Blastomyces-a thermally dimorphic fungus that can cause granulomatous and/or purulent infection. CASE PRESENTATION: We report here a case of chronic blastomycosis infection in a 24-year-old male patient from Saudi Arabia who presented with recurrent skin abscesses associated with deep-seated and multilevel paraspinal (dorsal and lumbar) collections and bilateral empyema with pulmonary involvement and bilateral psoas abscesses. The diagnosis was made after a CT-guided pleural biopsy revealed the characteristic histopathological findings of blastomycosis. The patient underwent several drainage procedures and was successfully treated with a long-term course of oral itraconazole. CONCLUSIONS: Chronic blastomycosis may have clinical and radiologic features similar to thoracic tuberculosis or malignant disease. There is no definite clinical symptom of blastomycosis, and thus a high degree of suspicion is required for early diagnosis. This case is a rare form of blastomycosis with chronic multifocal purulent infection and is the second case of blastomycosis reported in Saudi Arabia.

Intensive Care Unit and Hospital Outcomes of Patients Admitted with Blastomycosis: A 14-Year Retrospective Study.

INTRODUCTION: Blastomycosis is an uncommon; potentially life-threatening granulomatous fungal infection. The aim of this study is to report hospital and intensive care unit (ICU) outcomes of patients admitted with blastomycosis. METHODS: All patients admitted for treatment of blastomycosis at the Mayo Clinic-Rochester, Minnesota between 01/01/2006 and 09/30/2019 were included. Demographics, comorbidities, clinical presentation, ICU admission, and outcomes were reviewed. RESULTS: A total of 84 Patients were identified with 90 unique hospitalizations primarily for blastomycosis. The median age at diagnosis was 49 (IQR 28.1-65, range: 6-85) years and 56 (66.7%) were male. The most frequent comorbidities included hypertension (n = 28, 33.3%); immunosuppressed state (n = 25, 29.8%), and diabetes mellitus (n = 21, 25%). The lungs were the only organ involved in 56 (66.7%) cases and the infection was disseminated in 19 (22.6%) cases. A total of 29 patients (34.5%) underwent ICU admission due to complications of blastomycosis. ICU related events included mechanical ventilation (n = 20, 23.8%), acute respiratory distress syndrome (ARDS) (n = 13, 15.5%), tracheostomy (n = 9, 10.7%), renal replacement therapy (n = 8, 9.5%), and extracorporeal membrane oxygenation (ECMO) (n = 4, 4.8%). A total of 12 patients (14.3%) died in the hospital; all of whom had undergone ICU admission. In-hospital mortality was associated with renal replacement therapy (RRT) (P = 0.0255). CONCLUSION: Blastomycosis is a serious, potentially life-threatening infection that results in significant morbidity and mortality with a 34.5% ICU admission rate. RRT was associated with in-hospital mortality.

Reconstruction of full width, full thickness cicatricial eyelid defect after eyelid blastomycosis using a modified tarsoconjunctival flap advancement.

Following effective treatment with systemic antifungal therapy, eyelid lesions from blastomycosis infection may be replaced by disfiguring fibrosis and scarring, which may be surgically challenging to correct. A 68-year-old man with biopsy-proven eyelid blastomycosis was treated with 6 months of oral voriconazole, but resolution of the lesion was complicated by cicatricial changes causing complete lower eyelid defect, epicanthal web, cicatricial mechanical ptosis, and skin plaques. Although repair adhered to the fundamentals of eyelid reconstruction, cicatricial changes associated with blastomycosis infection necessitated a modified approach and attachment sites. A tarsoconjunctival flap (Hughes flap) with modified flap connections utilizing cicatrix and remaining viable tissue was employed to reconstruct the lower eyelid defect and combined with tissue advancement using a Mustardé four-flap epicanthoplasty and post-auricular full-thickness skin graft. Satisfactory cosmetic outcome was achieved at last follow-up of 3.5 months postoperatively. This case demonstrates a feasible technique for reconstruction of significant eyelid defects following robust cicatricial changes such as those after blastomycosis. This report also presents the first description of reconstruction of lower eyelid defect and of posterior lamellar loss after blastomycosis infection.

Disseminated blastomycosis in a patient with polycythemia vera on ruxolitinib.

Ruxolitinib (RUX) is a kinase inhibitor used in the treatment of various medical conditions and its mechanism of action involves suppression of the immune system. While beneficial in treatment of polycythemia vera, myelofibrosis and other indications, it can also increase a patient's susceptibility to various infections, including bacterial, viral and fungal. We present a case of a patient being treated with RUX who presented with a disseminated fungal infection. This case emphasises the need for vigilance of endemic fungal infections in individuals who are on RUX therapy.

Pulmonary Blastomycosis: A Rare Cause of Acute Chest Syndrome and Prolonged Fevers in a Pediatric Patient With Sickle Cell Disease.

Blastomyces is a fungus found in the soil of regions of North America including the Mississippi and Ohio River Valleys. It can be inhaled into the lungs and cause pneumonia and disseminated disease. Although blastomycosis is not widely reported in the sickle cell literature, sickle cell patients may be at increased risk of complications from blastomycosis pneumonia due to their immune compromise and risk of developing acute chest syndrome. We describe the case of a 13-year-old female with homozygous sickle cell disease who presented with pneumonia and acute chest syndrome and was found to have pulmonary blastomycosis.

An Unusual Presentation of Blastomycosis-Like Pyoderma Gangrenosum.

INTRODUCTION: Pyoderma gangrenosum (PG) is a complex disease that has the potential to mimic a wide variety of diseases and disorders. Pyoderma is a disease of exclusion, but it has many variants, including ulcerative, bullous, and pustular forms. Owing to the complexity of the disease, careful diagnosis is important because inappropriate treatment can result in wound recurrence. CASE REPORT: A 74-year-old female presented to the clinic with a presumed diagnosis of squamous cell carcinoma on biopsy but with an abnormal presentation mimicking a blastomycosis lesion. After surgical excision of the lesion in the operating room, the final pathology report confirmed the diagnosis of blastomycosis-like pyoderma gangrenosum. The patient was treated with high-dose prednisone and skin grafts, which resulted in resolution of the wound. CONCLUSIONS: This case report highlights the need to involve a wide array of health care providers in the management of complex and recurring wounds as well as the need to consider a wide and diverse differential diagnosis when determining the final diagnosis of complex wounds.

Detection of Blastomyces dermatitidis Antigen in Urine Using a Commercially Available Quantitative Enzyme Immunoassay.

Laboratory diagnosis of blastomycosis relies on a combination of methods, including antigen detection. We assessed the performance of analyte-specific reagents from Gotham Biotech (Portland, ME) for quantitative detection of Blastomyces dermatitidis galactomannan (GM) in urine using an enzyme immunoassay (EIA) compared to the Blastomyces quantitative EIA from MiraVista Diagnostics (Indianapolis, IN). Residual urine from 232 unique patients previously tested by the MiraVista assay was evaluated using the Gotham EIA, which showed 97.4% (74/76), 100% (156/156), and 99.1% (230/232) positive, negative, and overall agreement, respectively. Correlation between the quantitative B. dermatitidis antigen levels by the Gotham and MiraVista EIAs was low (R2 = 0.20). Medical records were available for 36 of the 232 patients, among whom four had confirmed blastomycosis and both the Gotham and MiraVista EIAs were positive. Nine of these patients had histoplasmosis, and the Gotham and MiraVista EIAs yielded negative results in 44.4% (4/9) and 22.2% (2/9) of cases, respectively. Both assays were negative in the remaining 23 patients. After laboratory implementation of the Gotham EIA, chart reviews were performed on the first 50 unique patients (51 samples) tested by the assay in our hospital. Among these, 3/50 (6%) samples were positive by the Gotham EIA, including two samples from a patient with culture-confirmed blastomycosis and one from a patient with histoplasmosis (also positive by the MiraVista Blastomyces EIA). All remaining patients were negative by the Gotham EIA and had alternative diagnoses. Our findings show comparable performance between the Gotham and MiraVista quantitative EIAs for detection of B. dermatitidis GM in urine.

Reconstruction Following Talectomy Due to Disseminated Blastomycosis in Immunocompetent Adult Utilizing Total Talus Prosthesis: A Case Report.

Blastomycosis is a rare condition affecting specific endemic areas in North America. Blastomycosis is characterized primarily as a pulmonary disease but can disseminate to affect other organ systems. Osteomyelitis due to disseminated blastomycosis is a rare condition with limited functional reconstructive options in a young adult. We present a rare case with prolonged antifungal therapy and staged reconstruction with a total talus prosthesis.

Blastomycosis with rapid-onset acute respiratory distress syndrome in an urban setting.

While blastomycosis is endemic to eastern USA and northwestern Ontario, acquisition is an anomaly in urban settings. We present a 54-year-old immunocompetent man from the greater Toronto area with no travel, who presented with a 3-week history of chest pain and dyspnoea. Initial radiographic workup revealed a mass-like opacification in the right apical mediastinum. Extensive investigations including bronchoscopy with bronchoalveolar lavage, mediastinal mass biopsy with fungal and mycobacterial cultures and multiple stains, and CT were unrevealing. The patient progressed to respiratory failure over 4 months. Ultimately, sputum and bone marrow cultures confirmed a diagnosis of disseminated blastomycosis. The patient required prolonged extracorporeal membrane oxygenation and ongoing ventilation postdecannulation. Our case highlights diagnostic challenges with blastomycosis, particularly in immunocompetent individuals with no travel to recreational areas, and emphasises the importance of maintaining a high index of suspicion and sending fungal cultures of appropriate specimens and/or cytopathology in clinically compatible cases.