Beware of the Acute Respiratory Distress Syndrome in a Pulmonary Blastomycosis!

Blastomyces dermatitidis is a dimorphic fungus that can range from mild to severe disease presentation, including the acute respiratory distress syndrome (ARDS) based on the individual's immunity. Acute respiratory distress syndrome is an uncommon presentation having an incidence of about 10% to 15% but has a high mortality exceeding 90%. This is a case of a 50-year-old female with past medical history of asthma and type 2 diabetes mellitus who presented to the pulmonology clinic with worsening dyspnea for the last 2 months. She also had a lesion in the left lower back, which was draining purulent fluid. Chest radiographs showed bilateral infiltrates and was started empirically on vancomycin and piperacillin-tazobactam. Bronchoalveolar lavage was done and the cultures grew B dermatitidis. The patient was moved to a higher level of care and given amphotericin B. Unfortunately, the patient experienced septic shock, which later deteriorated into cardiac arrest, ultimately leading to their passing. The importance of early diagnosis of blastomycosis and timely treatment has been emphasized in this case report.

Epistaxis and Facial Swelling Due to Nasal Blastomycosis in a Cat.

A 5 yr old castrated male domestic longhair was examined because of left-sided facial swelling and epistaxis. Head computed tomography with contrast identified a mass within the left nasal cavity and multifocal regions of nasal bone osteolysis. Histopathology of nasal mass biopsies and cytology of the facial swelling revealed pyogranulomatous inflammation due to Blastomyces dermatitidis. The cat experienced resolution of clinical signs following 8 mo of treatment with itraconazole. Although rare, clinicians should include blastomycosis on the differential diagnoses list of infectious causes for feline nasal disease if within an endemic area.

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.

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.

Does metabolite matter? Defining target itraconazole and hydroxy-itraconazole serum concentrations for blastomycosis.

BACKGROUND: Itraconazole is the recommended first-line treatment for mild-to-moderate blastomycosis and consolidation treatment of moderate-to-severe disease. Itraconazole is metabolised into three metabolites, including an active metabolite hydroxy-itraconazole. Literature provides little evidence indicating whether therapeutic drug monitoring targets should be based on itraconazole parent compound alone or a sum of itraconazole and hydroxy-itraconazole serum concentrations. OBJECTIVES: This study aims to compare clinical outcomes and adverse drug events (ADEs) of combined itraconazole and hydroxy-itraconazole concentrations versus itraconazole parent compound alone in patients with blastomycosis. PATIENTS/METHODS: This study was a retrospective cohort review of patients ≥18 years with probable or proven Blastomyces infection who received itraconazole with at least one documented serum itraconazole concentration. The primary outcome was rate of partial or complete treatment response across three patient groups: (1) Itraconazole parent compound >1.0 mcg/ml (parent), (2) parent compound <1.0 mcg/ml, but a combined itraconazole and hydroxy-itraconazole >1.0 mcg/ml (combined) and (3) failure to achieve a combined or parent concentration >1.0 mcg/ml (subtherapeutic) for >75% of the duration of itraconazole therapy. RESULTS: A total of 80 patients were included (parent = 32, combined = 36, subtherapeutic = 12). No statistically significant difference was observed for rate of partial or complete treatment response (97% parent vs 94% combined, p = .99). Significantly higher mortality due to blastomycosis was observed in patients in the subtherapeutic group (0% parent vs 3% combined vs 25% subtherapeutic, p = .01). CONCLUSIONS: This study supports an itraconazole therapeutic target combining itraconazole and hydroxy-itraconazole >1.0 mcg/ml for blastomycosis treatment.

Direct Tissue PCR and Genotyping for Species Identification in a Case of Laryngeal Blastomycosis.

Otolaryngologic manifestations of infection with Blastomyces species are extremely rare and restricted geographically to recognized endemic regions. Here, we describe a case of laryngeal blastomycosis that presented as slowly progressive dysphonia. While a preliminary diagnosis was made using routine histopathology, a species identification of Blastomyces dermatitidis was made using polymerase chain reaction amplification and rapid genotyping without the need for fungal culture. All symptoms resolved following 1 month of antifungal therapy. Rapid molecular differentiation of B dermatitidis from Blastomyces gilchristii provides important insights into pathogenesis given recent recognition of differences in clinical spectra.

Diagnostic delay in pulmonary blastomycosis: a case series reflecting a referral center experience.

PURPOSE: The diagnosis of pulmonary blastomycosis is usually delayed because of its non-specific presentation. We aimed to assess the extent of diagnostic delay in hospitalized patients and detect the step in the diagnostic process that requires the most improvement. METHODS: Adult patients diagnosed with pulmonary blastomycosis during a hospital admission between January 2010 through November 2021 were eligible for inclusion. Patients who did not have pulmonary involvement and who were diagnosed before admission were excluded. Demographics and comorbid conditions, specifics of disease presentation, and interventions were evaluated. The timing of the diagnosis, antifungal treatment, and patient outcomes were noted. Descriptive analytical tests were performed. RESULTS: A total of 43 patients were diagnosed with pulmonary blastomycosis during their admissions. The median age was 47 years, with 13 (30%) females. Of all patients, 29 (67%) had isolated pulmonary infection, while 14 (33%) had disseminated disease, affecting mostly skin and musculoskeletal system. The median duration between the initial symptoms and health care encounters was 4 days, and the time to hospital admission was 9 days. The median duration from the initial symptoms to the diagnosis was 20 days. Forty patients (93%) were treated with empirical antibacterials before a definitive diagnosis was made. In addition, corticosteroid treatment was empirically administered to 15 patients (35%) before the diagnosis, with indications such as suspicion of inflammatory processes or symptom relief. In 38 patients (88%), the first performed fungal diagnostic test was positive. Nineteen patients (44%) required admission to the intensive care unit, and 11 patients (26%) died during their hospital stay. CONCLUSION: There was a delay in diagnosis of patients with pulmonary blastomycosis, largely attributable to the lack of consideration of the etiological agent. Novel approaches to assist providers in recognizing the illness earlier and trigger evaluation are needed.

Negative Antigenuria in a Dog with Suspected Central Nervous System Localized Blastomycosis.

A 7 yr old female spayed mixed-breed dog was presented for a 1 wk history of neck pain and pelvic limb weakness. Examination revealed nonambulatory paraparesis and thoracolumbar hyperesthesia. MRI revealed extensive intramedullary T2-weighted/short tau inversion recovery hyperintensity and diffuse severe T1-post contrast meningeal enhancement of the thoracolumbar spinal cord. An L5-L6 cerebrospinal fluid sample revealed a suppurative pleocytosis (81% neutrophils, total protein 4362.5 mg/dL and nucleated cell count 352,000/µL). While awaiting the results of infectious disease testing, the dog was treated for suspected meningoencephalitis of unknown etiology with corticosteroids, cyclosporine, and a cytarabine arabinoside infusion. The dog neurologically declined and was started on broad-spectrum antibiotics. The dog continued to decline despite antibiotics, and infectious disease titers subsequently revealed serum antibody positivity for blastomycosis. The dog was then referred to a multispecialty referral hospital and was treated with amphotericin B followed by fluconazole. Prednisone was continued at anti-inflammatory doses. Urine blastomycosis antigen testing was submitted for subsequent disease monitoring but was negative. Five months after presentation the dog was clinically doing well with no identifiable neurologic deficits. This case demonstrates that neurologic blastomycosis may have negative urine antigen concentrations in some dogs and that other diagnostic modalities should be pursued when central nervous system fungal disease is suspected.

Disseminated blastomycosis with cutaneous involvement in a 57-year-old woman: a case report and review of management.

Blastomycosis is an infectious disease produced by the fungal organisms, Blastomyces dermatiditis and Blastomyces gilchristi. We present a 57-year-old woman with pulmonary blastomycosis and secondary cutaneous involvement. Her diagnosis was facilitated by dermatology consultation after approximately one year of delay. In endemic areas including Canada and the USA, individuals are at risk for blastomycosis when non-motile fungal spores are inhaled, thus producing pulmonary disease. The organism may disseminate over time, affecting a variety of extrapulmonary organ systems including the skin. In endemic regions of blastomycosis, this important cutaneous manifestation of disease should be considered with a high index of suspicion as to avoid delayed resolution and adverse outcomes.

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).

Radical treatment for blastomycosis following unsuccessful liposomal amphotericin.

Pulmonary blastomycosis is a respiratory disease that is caused by the fungus Blastomyces spp, which is acquired through inhalation of the fungal spores. Blastomycosis is relatively uncommon, with yearly incidence rate of 1-2 cases per 100 000 people. Blastomycosis is a disease that is endemic to the midwest and southern regions of the USA, most commonly affecting immunocompromised patients. About 50% of patients are asymptomatic, but for those who progress to acute respiratory distress syndrome (ARDS) mortality can be as high as 80%. Patients with severe blastomycosis are initially treated with intravenous amphotericin B, followed by long-term itraconazole maintenance therapy. In this Grand Round, we present the case of an immunocompetent 35-year-old man diagnosed with chronic pulmonary blastomycosis who had a poor response to 10 days of intravenous liposomal amphotericin B (L-AmB). He was endotracheally intubated and eventually cannulated for extracorporeal membrane oxygenation (ECMO), due to worsening respiratory function. L-AmB was replaced with a continuous infusion of intravenous amphotericin B deoxycholate (AmB-d). He improved significantly and was decannulated from ECMO on day 9 of AmBd continuous infusion and extubated on day 12 Although L-AmB is considered first-line treatment for blastomycosis, mortality remains high for patients with ARDS associated with blastomycosis. This case highlights the importance of considering AmB-d continuous infusions for patients with severe blastomycosis who might have poor clinical responses to L-AmB.

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.

Blastomycosis: The Great Pretender.

Blastomycosis is an endemic fungal infection caused by Blastomyces, a soil-dwelling dimorphic fungus found predominantly in North America. In this pictorial essay, we illustrate the varied imaging features of blastomycosis along with a brief description of the epidemiology, clinical aspects, and differential diagnosis, emphasizing clues that can help radiologists arrive at this diagnosis.