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PubMed2000

Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America.

Guidelines for the treatment of blastomycosis are presented; these guidelines are the consensus opinion of an expert panel representing the National Institute of Allergy and Infectious Diseases Mycoses Study Group and the Infectious Diseases Society of America. The clinical spectrum of blastomycosis is varied, including asymptomatic infection, acute or chronic pneumonia, and extrapulmonary disease. Most patients with blastomycosis will require therapy. Spontaneous cures may occur in some immunocompetent individuals with acute pulmonary blastomycosis. Thus, in a case of disease limited to the lungs, cure may have occurred before the diagnosis is made and without treatment; such a patient should be followed up closely for evidence of disease progression or dissemination. In contrast, all patients who are immunocompromised, have progressive pulmonary disease, or have extrapulmonary disease must be treated. Treatment options include amphotericin B, ketoconazole, itraconazole, and fluconazole. Amphotericin B is the treatment of choice for patients who are immunocompromised, have life-threatening or central nervous system (CNS) disease, or for whom azole treatment has failed. In addition, amphotericin B is the only drug approved for treating blastomycosis in pregnant women. The azoles are an equally effective and less toxic alternative to amphotericin B for treating immunocompetent patients with mild to moderate pulmonary or extrapulmonary disease, excluding CNS disease. Although there are no comparative trials, itraconazole appears more efficacious than either ketoconazole or fluconazole. Thus, itraconazole is the initial treatment of choice for nonlife-threatening non-CNS blastomycosis.

Amphotericin B↗

PubMed2000

Laryngeal blastomycosis: a commonly missed diagnosis. Report of two cases and review of the literature.

Blastomycosis is a relatively uncommon fungal disease that most commonly affects the lungs. Other organs may be involved, usually secondary to dissemination of the organism. Laryngeal blastomycosis may occur in isolation from active pulmonary disease. The signs, symptoms, clinical features, and pathological findings of laryngeal blastomycosis mimic those of squamous cell carcinoma. Misdiagnosis may result in inappropriate treatment with potential morbidity. Proper understanding of the clinical presentation and familiarity with the histopathologic features of this disease are therefore imperative. In this paper, we report 2 cases of laryngeal blastomycosis, 1 of which was misdiagnosed as squamous cell carcinoma, clinically and microscopically, with consequent radiotherapy and laryngectomy. In the other case, a clinical diagnosis of glottic squamous cell carcinoma was rendered. However, blastomycosis was identified in a biopsy specimen. We also review cases of isolated laryngeal blastomycosis that have been reported in the English-language literature during the last 80 years. A number of those cases were misdiagnosed clinically and microscopically as squamous cell carcinoma.

Amphotericin B↗

PubMed2002

Pulmonary blastomycosis: an appraisal of diagnostic techniques.

OBJECTIVES: Pulmonary blastomycosis often mimics bacterial pneumonia or bronchogenic carcinoma, which may result in delayed therapy or the performance of unnecessary diagnostic procedures. We have reviewed the utilization of diagnostic techniques in the workup of patients with pulmonary blastomycosis, defined their diagnostic yields, and proposed an optimal diagnostic approach for the patient in whom pulmonary blastomycosis is considered. DESIGN: Retrospective chart review of all patients with the diagnosis of blastomycosis at a major academic medical center. RESULTS: Of the 119 patients with blastomycosis, 56 (47%) had pulmonary involvement. A total of 92 specimens were obtained by noninvasive means (sputa, 72 specimens; tracheal secretions, 5 specimens; and gastric washings, 15 specimens) in 35 patients. KOH smears were prepared from 22 of those specimens (24%). The diagnostic yield from these culture specimens obtained by noninvasive means was 86% per patient, and 75% per single sample. The diagnostic yields from KOH smears were 46% and 36%, respectively. Flexible bronchoscopy was performed in 24 patients and yielded a diagnosis in 22 (92%). Cultures of bronchial secretions (19 patients) and BAL fluid (6 patients) were positive in 100% and 67% of patients, respectively. The corresponding yields of KOH preparations were 17% (1 of 6 preparations) and 50% (3 of 6 preparations), respectively. Pathology specimens including those from bronchoscopic lung biopsies (nine patients), bronchial brushings (two patients), and bronchoscopic needle aspiration (one patient) were positive in 22%, 50%, and 0% of cases, respectively. Cytology was usually performed to exclude malignancy and was positive for Blastomyces dermatitidis in five patients (sputum, three patients; bronchial washings, two patients). Thoracotomy was performed in 11 cases, and in all patients the procedure yielded a diagnosis. Serology results were available in 25 patients. Immunodiffusion was positive in 10 patients (40%), and complement fixation in 4 patients (16%). CONCLUSIONS: In patients with pulmonary blastomycosis, the positive yield from respiratory specimen cultures is high, but the confirmation of a diagnosis may take up to 5 weeks. Wet smears and cytology examinations of respiratory specimens provide quicker diagnoses but are underutilized. Their routine use is recommended in endemic areas. Commonly used serologic assays are insensitive and are not useful for diagnostic screening.

Adolescent↗

PubMed2004

Symptoms of pulmonary blastomycosis: northern Wisconsin, United States.

OBJECTIVE: Pulmonary disease is the most common manifestation of the systemic fungal infection, blastomycosis. This study examines symptoms of pulmonary blastomycosis and possible age and gender differences in a 22-year case series. METHODS: Laboratory-confirmed cases of blastomycosis were identified from mandatory reports to the Vilas County Health Department (1984--2001) and from hospital records and case contacts before mandated reports (November 1979--1983). Symptoms were ascertained by interviews of respondent cases (or next of kin) by using a standard form. Proportions were compared with the chi-square test or Fisher exact test. RESULTS: One hundred seventy cases of blastomycosis (mean age 44, 56% male) were identified and pulmonary manifestations were present in 154 (91%). Of the 118 interviewed cases, the following symptoms were common: cough (90%), fever (75%), night sweats (68%), weight loss (66%), chest pain (63%), dyspnea (54%), and aches (50%). Hemoptysis occurred in 18%, and nearly all queried patients had fatigue. The dyad of cough and fever occurred in 73%, and triads of fever-cough-night sweats, fever-cough-weight loss, and fever-cough-chest pain occurred in 58%, 57%, and 51%, respectively. Among men, fever (P = .03), cough and fever (P = .03), fever-cough-weight loss (P = .03), and fever-cough-night sweats (P = .03) were less common in those 50 years of age and older. Symptoms did not vary by duration of illness. CONCLUSIONS: Cough, fever, night sweats, weight loss, chest pain, dyspnea, and aches are common symptoms of pulmonary blastomycosis. Symptom constellations that included fever were less common in men 50 years of age and older. There was no apparent difference in symptoms between acute and chronic blastomycosis.

Adolescent↗

PubMed2001

Blastomycosis: more evidence for exposure near one's domicile.

BACKGROUND: Our previous publications on the epidemiology of blastomycosis suggested that the etiologic organism, Blastomyces dermatitidis, may be acquired at home, however this view was challenged in an editorial. METHODS: 1) Field study of 2 properties that preliminarily suggested disease acquisition in the home. Owner interviews, site visits and environmental cultures using our in-vitro technique were used. 2) An address registry of human and dog blastomycosis cases was constructed from extensions of our previously published case series. 3) Literature review. RESULTS: 1) Blastomycosis occurred in a dog (December, 1998) and then a cat confined to its home (September, 1999), from a household in urban Manitowoc County, WI; and additionally in a house-confined cat (July, 1998) at a home in Milwaukee, WI. Interviews implicated the basement and the attic or basement, respectively, as the most likely source of infection at these homes. Environmental cultures were negative for Blastomyces. Of the 229 domiciles in the registry, a minimum of 27 (12%) were associated with more than one blastomycosis case, 10 sites with more than two and 7 with more than three. In 4 domiciles, repeat cases occurred in different families. Most cases were separated by 1 year or more (range: 3 weeks to 7 years). Recent case series reveal a minority of outdoor activities and occupations among humans with blastomycosis. The organism has been isolated from an inhabited yard and from a house being razed. CONCLUSIONS: There appears to be growing evidence that blastomycosis may be acquired at home, and that B. dermatitidis may be relatively persistent on certain properties.

Animals↗

PubMed1996

Use of an amphotericin B lipid complex for treatment of blastomycosis in dogs.

OBJECTIVE: To evaluate efficacy and nephrotoxicity of amphotericin B lipid complex used for treatment of dogs with naturally developing blastomycosis. DESIGN: Prospective clinical trial. ANIMALS: 11 dogs with blastomycosis. PROCEDURE: All dogs were treated with an amphotericin B lipid complex. Two dogs received a cumulative dose of 8 mg/kg of body weight, 1 received a cumulative dose of 10 mg/kg, and 8 received a cumulative dose of 12 mg/kg. RESULTS: The 2 dogs that received a cumulative dose of 8 mg/kg and 1 of the dogs that received a cumulative dose of 12 mg/kg had a relapse of blastomycosis within 30 days after treatment. Seven of the remaining 8 dogs were clinically free of blastomycosis 6 months after treatment. One dog died of an unrelated cause 5.5 months after treatment, but did not have clinical signs of blastomycosis at the time of death. There were not any adverse clinical effects attributable to drug administration in any of the dogs in this study, and none of the dogs developed clinical signs of renal disease or failure. CLINICAL IMPLICATIONS: Amphotericin B lipid complex was a safe and effective treatment for blastomycosis in these dogs.

Amphotericin B↗

PubMed1997

Blastomycosis in six dogs in New York state.

Blastomycosis was diagnosed in 6 dogs living in New York state. To our knowledge, blastomycosis has not been previously reported in dogs in this area, and maps that indicate the prevalence of blastomycosis in North America often partially or completely exclude the state of New York. Environmental characteristics implicated in previous blastomycosis outbreaks in people can be found in New York state, and this may explain how these dogs became infected. Blastomycosis develops in people as well as in dogs, and an understanding of the ecologic and clinical features of blastomycosis can help veterinarians counsel their clients in matters of public health.

Animals↗

PubMed1998

Blastomycosis in dogs: 115 cases (1980-1995).

OBJECTIVE: To characterize diagnostic results, treatment, and outcome of dogs with blastomycosis during a 15-year period in Louisiana. DESIGN: Retrospective case series. ANIMALS: 115 dogs with blastomycosis. PROCEDURE: Medical records were reviewed for dogs with blastomycosis examined between 1980 and 1995. Additional data were collected from the state veterinary diagnostic laboratory, via telephone interviews of owners, and by use of a random survey of the hospital population. RESULTS: Blastomycosis was detected mainly in young, large-breed dogs. Proximity to a body of water was a significant risk factor for affected dogs. Most dogs were affected in January and August through October. Clinical signs and results of physical examination reflected the multisystemic nature of the disease. Commonly affected systems included the respiratory tract and lymphatic, ocular, and cutaneous systems. Nodular interstitial and interstitial patterns were common findings on thoracic radiographs. Cytologic examination was successful in identifying organisms in samples from vitreous, skin, and lymph nodes. Similar results were achieved for dogs treated with a combination of amphotericin B and ketoconazole, compared with dogs treated with itraconazole. CLINICAL IMPLICATIONS: Results of this study should assist veterinarians with the recognition and management of blastomycosis in dogs. Blastomycosis should be considered as a differential diagnosis for large-breed dogs that live close to a body of water in areas in which the disease is endemic or in dogs with a history of being transported to endemic areas that subsequently develop signs of pulmonary, ocular, lymphatic, or cutaneous disease. Treatment with itraconazole was as effective as treatment with a combination of amphotericin B and ketoconazole.

Age Distribution↗

PubMed2002

Characterization of uptake of 2-deoxy-2-[18F] fluoro-D-glucose by fungal-associated inflammation: the standardized uptake value is greater for lesions of blastomycosis than for lymphoma in dogs with naturally occurring disease.

PURPOSE: Based on limited reports, fungal lesions can have remarkably high intensity uptake of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) on positron emission tomography (PET) images. The purpose of this investigation was to compare the standardized uptake value (SUV) of naturally occurring lesions of blastomycosis with the SUV of naturally occurring lymphoma in a series of dogs. PROCEDURES: Five dogs with naturally occurring blastomycosis and three dogs with lymphoma underwent whole-body FDG-PET prior to receiving any treatment for their disease. RESULTS: The (mean +/- SD) SUV for 13 blastomycosis lesions was 7.7 +/- 2.0 versus a mean for 17 lymphomas of 4.8 +/- 1.8. These values were significantly different (P = 0.0537). There was overlap between the SUV of Blastomyces-associated lesions versus lymphomas, but a cut-off SUV of 7.0 was 100% specific for Blastomyces lesions. Numerous sites of disease were detected on the FDG-PET images that were not detected clinically. CONCLUSIONS: FDG-PET is useful for determining the extent of disease in dogs with blastomycosis. The SUV for Blastomyces-associated lesions are as high or higher than for malignant lymphoma. Due to the similarities in canine and human blastomycosis and lymphomas, similar results would be predicted in human patients. In regions where blastomycosis is endemic, Blastomyces granulomas should be considered a differential diagnosis for lesions with high intensity uptake of FDG.

Journal Article↗

PubMed2005

Secondary intracerebral blastomycosis with giant yeast forms.

Secondary central nervous system (CNS) blastomycosis is an unusual manifestation of blastomycosis. We report a case of recurrent intracerebral blastomycosis that presented histopathologically with giant yeast-like cells and multinucleation that mimicked Coccidioides immitis. The yeast forms of Blastomyces dermatitidis usually range in size from 8 to 20 microm in diameter. Large or giant yeast forms (20-40 microm) are rare. The four cases previously reported in the literature involving giant yeast cell forms of B. dermatitidis are reviewed here. Intracerebral blastomycosis should be suspected in patients with signs and symptoms of CNS lesions and histories of primary blastomycosis, or treatment with corticosteroids, or comprised immune systems. The diagnosis should be confirmed by culture which presents typical biphasic microbiologic features.

Adolescent↗

PubMed2000

Chronic paronychia, osteomyelitis, and paravertebral abscess in a child with blastomycosis.

Blastomycosis is an unusual fungal infection in children. It is often a chronic infection characterized by granulomatous and suppurative lesions. Clinical manifestations include either pulmonary findings or disseminated disease. Disseminated blastomycosis usually begins with a lung infection that spreads to the skin, bones, and central nervous system. This is a case report of a child with chronic blastomycosis presenting with chronic paronychia, fever, cough, malaise, and back pain. The child underwent surgical drainage of a paravertebral abscess and administration of intravenous amphotericin B. He was discharged in good condition on oral therapy with ketoconazole. The literature on blastomycosis, with particular emphasis on clinical presentations and management, is reviewed. When the history and physical examination suggest a chronic granulomatous or disseminated disease, such as tuberculosis, the physician must include blastomycosis in the differential.

Abscess↗

PubMed2004

Intramedullary blastomycosis in a child: case report.

OBJECTIVE: To report a case of spinal intramedullary blastomycosis causing myelopathy. CLINICAL PRESENTATION: An otherwise healthy 13-year-old patient was diagnosed with respiratory North American blastomycosis. She subsequently received a five-month course of itraconazole with presumed resolution of the infection. The patient presented again at 14 years of age with a lumbar myelopathy. Magnetic resonance imaging revealed an intramedullary lesion of 1 cm diameter at the level of T12-L1. INTERVENTION: A T12-L1 laminectomy was performed with a gross total resection of the lesion. Pathological examination and microbiological culture of the specimen was consistent with blastomycosis. Postoperatively, the patient was placed on a five week course of amphotericin B. The patient showed substantial improvement in neurological function. CONCLUSION: Blastomycosis can present as an isolated intramedullary lesion causing compromised function. It should be considered in the differential diagnosis of a patient with a myelopathy and previously recognized blastomycosis. The prognosis is good with surgical resection.

Adolescent↗

PubMed1980

Epidemiological studies on blastomycosis in the state of Wisconsin.

A study was made of 73 Wisconsin cases of canine blastomycosis. Each case was studied with respect to the life history of the animal. It was considered that a large percentage of the dogs were infected while in Wisconsin, since 40 had never left the state, and it was highly probable that in a large percentage of the other 33 cases the disease was contracted while the dog resided in Wisconsin. A study of the cases with respect to county of residence, birth and visitation revealed that there were three regions in the state where blastomycosis was prevalent: one region in the southeast and two regions in the northern parts of the state. An increase in the number of canine cases of blastomycosis over the years was considered to result from an increase in the skill of the veterinarian in diagnosing the disease. It was thought that a similar increase in number of human cases reported in recent years resulted from improvements in isolation techniques. The number of canine cases, 75, and human cases, 182, published up to now were considered to be minimum figures since many cases remain unpublished. A study of contiguous human and canine cases of blastomycosis lent support to the hypothesis that Ajellomyces (Blastomyces) dermatitidis conidia may be disseminated in fog or mist. Two cases of feline blastomycosis diagnosed in Wisconsin are reported for the first time. One cat acquired the disease in the state: the origin of the infection of the second cat was equivocal since it spent its summers in Wisconsin and its winters in another endemic state.

Animals↗

PubMedDate not supplied

The epidemiology of blastomycosis in dogs: north central Wisconsin, USA.

The epidemiological features of 59 consecutive cases of blastomycosis in domestic dogs, from a single veterinary practice in Eagle River, Wisconsin over a 3-year period, were examined by owner interview. The control sample included: (i) all porcupine quill-injured dogs during this time period (outdoor exposed dogs); and (ii) every sixth dog receiving a rabies vaccination during the second year of study (representative of all dogs in the practice). The estimated mean annual incidence of blastomycosis in dogs in this region was 1420:100,000. Blastomycosis cases were more likely to reside within 400 m of a waterway (95%) than quill-injured dogs (63%, P < 0.001) or vaccinated dogs (74%, P = 0.001). Exposure to an excavation was significantly more likely among blastomycosis cases compared to quill-injured dogs, however, no differences were found for age, sex, hunting, swimming and reported exposure to beavers. The geographical clustering of cases in dogs is similar to that previously reported for humans in this region. A close proximity to waterways and an exposure to excavation are significant risk factors for blastomycosis.

Animals↗

PubMed2006

Cerebral blastomycosis: a case series incorporating voriconazole in the treatment regimen.

Cerebral blastomycosis is a rarely reported disease. We report three cases of cerebral blastomycosis previously treated with standard antifungal therapy, which were subsequently successfully treated with voriconazole. The first is a 29-year-old man who initially presented with concomitant cutaneous and osseous blastomycosis; the second is a 50-year-old man who initially presented with prostatic, pulmonary and cutaneous lesions. The third patient was a 63-year-old man who presented with hemiplegia and multiple intra-cerebral blastomycomas. This report represents the first two documented relapses, in Canada, of CNS blastomycosis following treatment with itraconazole and, to our knowledge, among the first three worldwide human cases of cerebral blastomycosis treated successfully with voriconazole.

Adult↗

PubMed2002

Epidemiology and clinical spectrum of blastomycosis diagnosed at Manitoba hospitals.

Blastomyces dermatitidis is a dimorphic fungus endemic to Canada and the United States. Few reports regarding blastomycosis in Canada have been published. We retrospectively reviewed the medical charts of 143 patients with confirmed cases of blastomycosis diagnosed in hospitals in Manitoba, Canada, from 1988 through 1999. The annual incidence rate of blastomycosis in Manitoba was 0.62 cases per 100,000 population, compared with 7.11 cases per 100,000 population in the Kenora, Ontario district. The average age of patients was 38.0 years, and males accounted for 65.0% of cases. An increased incidence of blastomycosis was observed in the Aboriginal subpopulation. Organ systems involved were as follows: respiratory system (93.0% of cases), skin (21.0%), bone (13.3%), genitourinary tract (1.4%), and the central nervous system (1.4%); 6.3% of patients died, and death was associated with a short clinical course. This study provides a summary of the current status of blastomycosis in this area of endemicity in Canada.

Adolescent↗

PubMed1998

Vertebral blastomycosis with paravertebral abscess: report of eight cases and review of the literature.

Bone is the third most frequent site of disease in patients with blastomycosis, and the vertebrae are among the bones affected most often. We describe the clinical features and treatment of eight patients with vertebral blastomycosis and review the literature regarding this disease. All eight patients had destructive vertebral lesions evident on radiographs, and all had clinical or radiographic evidence of a contiguous abscess. The lower thoracic or lumbar regions were affected most often. Fever and skin lesions typical of blastomycosis were variably present. All but one patient had an abnormal chest radiograph. Treatment included long-term antifungal therapy and drainage of large fluid collections. Five of the eight patients were cured of their disease. Of the other 3 patients, 1 is still receiving therapy and is probably cured, 1 died of blastomycosis, and the status of 1 is unknown. In areas of endemicity, blastomycosis should be a diagnostic consideration for any patient with a destructive vertebral lesion.

Abscess↗

PubMed1991

Asymptomatic blastomycosis of the central nervous system with progression in patients given ketoconazole therapy: a report of two cases.

Ketoconazole (KTZ) has largely replaced amphotericin B as first-line therapy for blastomycosis. However, KTZ penetrates poorly into the central nervous system (CNS), and therapeutic failure may be caused by initially unrecognized CNS infection. Two patients (22% [2/9] of all culture-proven cases of blastomycosis at Grady Memorial Hospital, Atlanta, over 15 years) developed CNS blastomycosis while receiving KTZ. Neither initially had CNS symptoms; both had cutaneous and pulmonary disease that responded to KTZ. If KTZ or other fungistatic imidazoles are to continue as primary therapy for blastomycosis, studies are needed to improve the ability to identify patients likely to experience treatment failure or develop CNS disease. Possibly all patients with disseminated blastomycosis, even those without CNS symptoms, should have lumbar puncture and computed tomography of the head before therapy. Critical evaluation of their immune function also may be required before making a therapeutic decision to use KTZ or amphotericin B.

Aged↗