ABSTRACT
Blastomycoses dermatitidis is a dimorphic fungus that can cause disseminated blastomycosis with varying clinical manifestations and multiorgan involvement. While blastomycosis commonly causes pulmonary disease, extrapulmonary spread can result in skin, bone, and central nervous system involvement. Cutaneous blastomycosis can present as pustular lesions that evolve into ulcerative or verrucous plaques. We present a case of disseminated blastomycosis in an immunocompetent patient with both pulmonary and cutaneous features. The patient developed hypoxic respiratory failure and was subsequently diagnosed with disseminated blastomycosis after undergoing bronchoscopy with bronchial washing. He was found to have ulcerative nasal lesions as part of his disseminated disease. He was successfully treated with amphotericin B and ultimately discharged from the hospital.
Subject(s)
Blastomycosis , Immunocompetence , Humans , Blastomycosis/diagnosis , Blastomycosis/drug therapy , Male , Antifungal Agents/therapeutic use , Amphotericin B/therapeutic use , Amphotericin B/administration & dosage , Middle Aged , Blastomyces/isolation & purificationABSTRACT
INTRODUCTION: Blastomycosis is a fungal infection caused by Blastomyces dermatitidis that is hyperendemic in Wisconsin. It commonly presents as a pulmonary infection and frequently disseminates to the skin. Studies evaluating the presentation and diagnosis of blastomycosis with skin as a presenting sign have not been thoroughly evaluated, and understanding the most accurate way to diagnose this infection is important for earlier therapeutic intervention. METHODS: This is a retrospective chart review study of a single institution. Subjects were identified through a search of ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes for blastomycosis in the clinical record and pathology database. Patients were included if diagnosed with cutaneous blastomycosis infection or involvement of the skin from systemic infection from January 1, 2009, to June 1, 2021. RESULTS: Twenty patients with a diagnosis of cutaneous involvement of blastomycosis were identified; 65% (n = 13) were male. Median age of diagnosis was 55.5 years. Fifty-five percent of patients were White, 35% were Black or African American. In addition to residence in an endemic area, 50% (n = 10) had exposure risk factors. Fifty percent of patients (n = 10) initially presented with a skin concerns; 65% (n = 13) had extracutaneous involvement. Diagnosis was made by histopathology alone in 55% (n = 11), culture plus histopathology in 35% (n = 7), and culture alone in 5% (n = 1) of cases. CONCLUSIONS: Our study highlighted similarities to those previously performed. Half of the patients (n = 10) who had cutaneous involvement of blastomycosis did not demonstrate clinically significant pulmonary involvement. Histopathology and culture remain critical in diagnosing cutaneous blastomycosis.
Subject(s)
Blastomycosis , Humans , Wisconsin/epidemiology , Blastomycosis/diagnosis , Blastomycosis/epidemiology , Male , Female , Retrospective Studies , Middle Aged , Adult , Aged , Risk Factors , Blastomyces/isolation & purificationABSTRACT
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.
Subject(s)
Acute Chest Syndrome/pathology , Anemia, Sickle Cell/physiopathology , Blastomyces/isolation & purification , Blastomycosis/complications , Lung Diseases, Fungal/complications , Pneumonia/complications , Acute Chest Syndrome/etiology , Adolescent , Blastomycosis/microbiology , Female , Humans , Lung Diseases, Fungal/microbiology , Pneumonia/microbiology , PrognosisABSTRACT
Blastomycosis is a prominent fungal disease in the United States. Vitamin D status has been found to be altered in critical illness and various infectious diseases. The objectives of this study were to compare serum 25-hydroxyvitamin D (25[OH]D) concentrations in dogs with blastomycosis and healthy controls, to assess the change in serum 25(OH)D concentrations in dogs with blastomycosis after 30 days of treatment, and to determine if baseline serum 25(OH)D concentrations in dogs with blastomycosis were associated with in-hospital, 30-day, or end-of-study mortality. In this prospective cohort study, 19 dogs newly diagnosed with blastomycosis had serum 25(OH)D concentrations measured with a commercially available validated radioimmunoassay at the time of diagnosis and 30 days after start of treatment. These values were compared to 24 healthy control dogs. Serum 25(OH)D concentrations at the time of diagnosis were lower in dogs with blastomycosis (median, 203 nmol/L; range, 31-590 nmol/L) than in clinically healthy control dogs (259.5 nmol/L, 97-829 nmol/L; P = 0.01). Despite clinical improvement, there was no significant change in serum 25(OH)D concentrations from baseline to 30-day follow-up. Dogs with baseline serum 25(OH)D concentrations <180.5nmol/L had a greater odds of death during hospitalization (odds ratio [OR], 15.0; 95% confidence interval [CI], 1.4-191.3; P = 0.04) and at 30 days follow-up (OR, 30.0; 95% CI, 2.5-366.7; P = 0.006). These findings highlight the need for further studies evaluating the prognostic value of vitamin D status in dogs with blastomycosis at diagnosis and throughout treatment and remission.
Subject(s)
Antifungal Agents/therapeutic use , Blastomycosis/veterinary , Dog Diseases/blood , Vitamin D/analogs & derivatives , Animals , Blastomyces/isolation & purification , Blastomycosis/blood , Blastomycosis/drug therapy , Blastomycosis/mortality , Cohort Studies , Dog Diseases/drug therapy , Dog Diseases/mortality , Dogs , Female , Male , Prospective Studies , Vitamin D/bloodSubject(s)
Abscess/surgery , Amphotericin B/administration & dosage , Antifungal Agents/therapeutic use , Blastomyces/isolation & purification , Blastomycosis/complications , Blastomycosis/drug therapy , Drainage , Scapula/diagnostic imaging , Abscess/microbiology , Adult , Amphotericin B/therapeutic use , Blastomycosis/diagnosis , Bronchoalveolar Lavage , Humans , Male , Scapula/pathology , Treatment OutcomeABSTRACT
BACKGROUND: Blastomycosis, an endemic mycosis of immunocompetent individuals, is typically seen after exposure to waterways within rural wooded regions. It is not considered a disease of urban environments. Infection can be solely pneumonic or disseminate to skin, bone or central nervous system. Unknown factors influence disease acquisition and severity in children. METHODS: We analyzed acquisition risks and disease characteristics of blastomycosis in children seen at a tertiary care center from 1998 to 2018 to identify potential exposure sources, measure disease severity and assess the effect of race upon disease severity. RESULTS: Of 64 infected children, mean age was 12.9 years, with median time to diagnosis 38.5 days. About 72% were male, 38% resided in urban counties and 50% had typical environmental exposure. Isolated pulmonary infection occurred in 33 (52%). The remainder had evidence of dissemination to skin (N = 13), bone (N = 16; 7 clinically silent) and cranium (N = 7; 3 clinically silent). Infection was moderate/severe in 19 (30%). Two children (3%) died. About 79% of children with moderate/severe disease (P = 0.008) and 71% of urban children (P = 0.007) lacked typical environmental exposure. Comparing children from urban counties to other residences, 63% versus 5% were black (P < 0.001) and 71% versus 35% developed extrapulmonary dissemination (P = 0.006). Moderate/severe disease was seen in 7/17 (42%) black children but only 12/47 (26%) children of other races (P = 0.23). CONCLUSIONS: Blastomycosis, can be endemic in urban children in the absence of typical exposure history, have frequent, sometimes clinically silent, extrapulmonary dissemination and possibly produces more severe disease in black children.
Subject(s)
Blastomyces/genetics , Blastomycosis/microbiology , Patient Acuity , Urban Population/statistics & numerical data , Adolescent , Black or African American/statistics & numerical data , Blastomyces/isolation & purification , Blastomycosis/diagnosis , Blastomycosis/ethnology , Child , Child, Preschool , Female , Humans , Infant , Infant, Newborn , Male , Retrospective Studies , Risk Factors , Tertiary Care Centers/statistics & numerical data , WisconsinABSTRACT
A previously healthy 15-year-old boy from a rural county in the southeastern United States was evaluated in the emergency department with fever and worsening toe pain in the absence of trauma. He initially presented to his primary care physician 4 weeks before with upper respiratory symptoms and was treated with corticosteroids for presumed reactive airway disease. His respiratory symptoms resolved. One week after this presentation, he developed fever and right great toe pain and presented to an outside hospital. Inflammatory markers were elevated. MRI confirmed a diagnosis of osteomyelitis with associated periosteal abscess. He was treated with intravenous antibiotics and drainage of the abscess. Ten days after his discharge from the outside hospital, he developed fever and had increasing drainage of the toe and pain refractory to oral pain medications. He presented to our facility for further evaluation. Repeat MRI and inflammatory markers corroborated his worsening disease, and he was admitted to the hospital for intravenous antibiotics and underwent serial surgical debridement. He developed painful subcutaneous nodules on his lower extremities and was found to have lung abnormalities on chest radiograph. A multispecialty team collaborated in the management of this patient and unveiled a surprising diagnosis.
Subject(s)
Abscess/microbiology , Blastomycosis/diagnosis , Fever/microbiology , Hallux , Osteomyelitis/microbiology , Pain, Intractable/etiology , Agricultural Workers' Diseases/microbiology , Amputation, Surgical , Anti-Bacterial Agents/therapeutic use , Antifungal Agents/therapeutic use , Blastomyces/isolation & purification , Blastomycosis/complications , Daptomycin/therapeutic use , Disease Progression , Hallux/surgery , Humans , Itraconazole/therapeutic use , MaleSubject(s)
Blastomyces/isolation & purification , Blastomycosis/microbiology , Cytomegalovirus Infections/virology , Cytomegalovirus/isolation & purification , Esophagitis , Herpes Simplex/virology , Immunocompromised Host , Opportunistic Infections , Simplexvirus/isolation & purification , Aged , Biopsy , Blastomyces/immunology , Blastomycosis/diagnosis , Blastomycosis/immunology , Coinfection , Cytomegalovirus/immunology , Cytomegalovirus Infections/diagnosis , Cytomegalovirus Infections/immunology , Endoscopy, Digestive System , Esophagitis/diagnosis , Esophagitis/immunology , Esophagitis/microbiology , Esophagitis/virology , Herpes Simplex/diagnosis , Herpes Simplex/immunology , Humans , Immunosuppressive Agents/adverse effects , Kidney Transplantation/adverse effects , Male , Opportunistic Infections/diagnosis , Opportunistic Infections/immunology , Opportunistic Infections/microbiology , Opportunistic Infections/virology , Simplexvirus/immunologySubject(s)
Blastomycosis/diagnosis , Bone Diseases/diagnosis , Bone Diseases/drug therapy , Adult , Biopsy , Blastomyces/isolation & purification , Blastomycosis/drug therapy , Blastomycosis/surgery , Bone Diseases/surgery , Bone Neoplasms/diagnosis , Diagnosis, Differential , Humans , Ilium/microbiology , Ilium/pathology , Itraconazole/therapeutic use , Magnetic Resonance Imaging , Male , Tomography, X-Ray ComputedABSTRACT
CASE: We describe a case of biopsy-proven blastomycosis in a patient residing in Upstate New York with osseous and skin lesions and no pulmonary or constitutional symptoms. The patient had a rapid resolution of symptoms after the initiation of antifungal treatment, followed by curettage and cementation of her distal femoral lesion. CONCLUSIONS: Orthopaedic surgeons should be aware of the presence of blastomycosis in nonendemic areas, especially since bone involvement may be the predominant manifestation. Tissue should be submitted for both histologic and microbiologic analysis. Antifungal therapy and surgical management if needed can result in a good outcome.
Subject(s)
Blastomycosis/diagnosis , Bone Diseases/diagnosis , Bone Diseases/microbiology , Blastomyces/isolation & purification , Blastomycosis/therapy , Bone Diseases/therapy , Female , Humans , Middle AgedSubject(s)
Blastomycosis/diagnostic imaging , Lymph Nodes/diagnostic imaging , Lymphadenopathy/diagnostic imaging , Sarcoidosis/diagnosis , Soft Tissue Infections/diagnosis , Solitary Pulmonary Nodule/diagnostic imaging , Acute Disease , Adult , Antifungal Agents/therapeutic use , Blastomyces/genetics , Blastomyces/isolation & purification , Blastomycosis/drug therapy , Blastomycosis/pathology , Bronchoscopy , California , DNA, Fungal/genetics , Diagnosis, Differential , Endoscopic Ultrasound-Guided Fine Needle Aspiration , Female , Fever , Humans , India/ethnology , Itraconazole/therapeutic use , Lymph Nodes/pathology , Lymphadenopathy/pathology , Ohio , Sequence Analysis, DNA , Soft Tissue Infections/drug therapy , Solitary Pulmonary Nodule/drug therapy , TexasABSTRACT
Background: Dimorphic fungi may cause infections and symptoms similar to tuberculosis (TB), in humans and animals. Such infections, individually or concurrently with TB, have been identified in cattle in Kenya, raising the possibility of infections in other animals, including humans. The study aimed to identify and quantify dimorphic fungi co-infection in persons with TB. Methods: Smear-positive sputum samples, 400, were obtained from TB clinics between October 2016 and November 2017. The samples were examined microscopically for yeast fungi, cultured for isolation of yeast, conversion to molds, and conversion from molds to yeasts. The isolates were characterized morphologically. Results: Blastopores, with morphological characteristics of Paracoccidiodes and Blastomyces, were observed in 37 smears of the sputum samples. Similar yeast cells were observed in smears of the sputum cultures. The yeast cultures were converted to molds on incubation at room temperature and back to yeasts on incubation at 37°C. Conclusion: Dimorphic fungi, morphologically identified as Paracoccidiodes and Blastomyces, concomitantly infect a proportion of TB patients in the study area. It is recommended that routine diagnosis for TB should consider infection or co-infection by dimorphic fungi for institution of appropriate treatment.
Subject(s)
Coinfection/microbiology , Fungi/isolation & purification , Sputum/microbiology , Tuberculosis/microbiology , Animals , Blastomyces/isolation & purification , Cattle , Coinfection/epidemiology , Fungi/classification , Fungi/pathogenicity , Humans , Kenya/epidemiology , Mycobacterium tuberculosis/isolation & purification , Paracoccidioides/isolation & purification , Tuberculosis/epidemiology , Tuberculosis/transmissionABSTRACT
A 9 yr old female spayed Labrador retriever presented for progressive dyspnea. Inspiratory stridor and inspiratory and expiratory dyspnea were present, consistent with an upper airway obstruction. A laryngeal exam revealed severe thickening of the arytenoid cartilages and masses associated with the arytenoids. A tracheostomy tube was placed, and the masses were biopsied. Histopathology showed pyogranulomatous inflammation secondary to Blastomyces dermatitidis. The dog was initially treated with amphotericin B and terbinafine in the hospital until the airway obstruction resolved and the tracheostomy tube could be removed. The dog experienced complete recovery after long-term treatment with itraconazole and terbinafine. This is the first report of laryngeal obstruction secondary to primary laryngeal blastomycosis in a dog. Blastomycosis should be considered for cases of obstructive laryngeal disease, and a good outcome can be achieved with antifungal treatment.
Subject(s)
Airway Obstruction/veterinary , Blastomyces/isolation & purification , Blastomycosis/veterinary , Dog Diseases/diagnosis , Laryngeal Diseases/veterinary , Airway Obstruction/etiology , Amphotericin B/administration & dosage , Amphotericin B/therapeutic use , Animals , Antifungal Agents/administration & dosage , Antifungal Agents/therapeutic use , Blastomycosis/complications , Blastomycosis/diagnosis , Diagnosis, Differential , Dog Diseases/drug therapy , Dogs , Female , Laryngeal Diseases/complications , Laryngeal Diseases/diagnosis , Pedigree , Terbinafine/administration & dosage , Terbinafine/therapeutic use , Tracheostomy/veterinaryABSTRACT
Drug pharmacokinetics may be significantly altered in patients receiving extracorporeal membrane oxygenation (ECMO). Ensuring the optimized effective dosing of antimicrobials on ECMO remains a challenge. To date, limited data are available regarding the optimal use of amphotericin and triazoles during ECMO. We report a case of altered pharmacokinetics, insufficient liposomal amphotericin B and isavuconazole levels, and the need for escalated doses during ECMO in a patient with severe acute respiratory distress syndrome secondary to pulmonary blastomycosis. A 2-fold increase in the standard total daily dose of both drugs was necessary to overcome low serum concentrations thought to be secondary to drug loss from ECMO circuit sequestration. These findings have important implications for optimizing antimicrobial therapy in patients receiving ECMO to maximize therapeutic efficacy. The use of therapeutic drug monitoring for patients receiving antimicrobial therapy with concurrent ECMO may facilitate appropriate drug dosing to achieve adequate serum concentrations and optimize favorable patient outcomes. Further studies exploring antimicrobial pharmacokinetics during ECMO are needed to inform dosing recommendations in critically ill patients.
Subject(s)
Amphotericin B/therapeutic use , Antifungal Agents/therapeutic use , Blastomycosis/therapy , Extracorporeal Membrane Oxygenation , Adult , Amphotericin B/administration & dosage , Amphotericin B/pharmacokinetics , Antifungal Agents/administration & dosage , Antifungal Agents/pharmacokinetics , Blastomyces/isolation & purification , Blastomycosis/blood , Blastomycosis/complications , Cough/etiology , Dyspnea/etiology , Fever/etiology , Humans , MaleABSTRACT
Chronic pulmonary blastomycosis is often misdiagnosed and treated as tuberculosis in disease-endemic and non-disease-endemic areas. We report the case of a 32-year-old man who after visiting Chicago, Illinois, USA, returned to India and received treatment for tuberculosis for 12 months before receiving the correct diagnosis of blastomycosis.
Subject(s)
Blastomyces/isolation & purification , Blastomycosis/diagnosis , Lung Diseases, Fungal/diagnosis , Adult , Antifungal Agents/therapeutic use , Blastomycosis/drug therapy , Blastomycosis/microbiology , Chicago , Diagnosis, Differential , Diagnostic Errors , Humans , India , Lung Diseases, Fungal/drug therapy , Lung Diseases, Fungal/microbiology , Male , Travel , Tuberculosis, Pulmonary/diagnosisABSTRACT
Talaromyces marneffei is a fungal opportunistic infection usually seen in immunocompromised patients from eastern countries. In the US when examining HIV-patients for suspected fungal infections, laboratory serological tests guide therapy until cultures are available. We present the case of a 35-year-old HIV patient originally from Thailand in which urine lab results were positive for Blastomyces and Histoplasma antigen, but biopsy showed T. marneffei. Concomitantly the patient presented with hyponatremia which was deemed to be from SIADH. We present the first case of a patient with T. marneffei cross reactivity with Blastomyces, Histoplasma and SIADH due to pulmonary disease.