South American Blastomycosis 

  • Author: Julie E Dixon, MD, FAAD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 24, 2012
 

Background

South American blastomycosis is a serious, systemic mycotic infection caused by the thermally dimorphic fungus Paracoccidioides brasiliensis. The fungus is endemic to countries in Central America and South America, most notably Brazil, Argentina, Colombia, and Venezuela, in regions classified as subtropical mountain forests. Infection with P brasiliensis is usually subclinical; however, the fungus sometimes proliferates, causing severe disease.[1]

Two general forms of the disease exist: the subacute juvenile form and the chronic adult form. The chronic adult form accounts for more than 90% of cases. The lungs, skin, mucous membranes, and lymph nodes most frequently are involved. Other internal organs sometimes are affected. Also see Blastomycosis (pediatrics) and Blastomycosis (pulmonology).

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Pathophysiology

P brasiliensis is a thermally dimorphic fungus that grows as a mycelium in nature and as yeastlike cells in tissue. Although P brasiliensis has been cultured from the soil, its natural habitat is not well understood. The disease is believed to be initially acquired through the inhalation of the fungus, as with other dimorphic fungi. After the inhalation of conidia, the fungus transforms into yeast cells within the alveolar macrophages. In most patients who are immunocompetent, infection is subclinical, and fungal growth is halted. However, in some patients, after an incubation period of weeks to decades, the fungus reactivates and disseminates, causing granulomatous disease in multiple tissues.[2] Most commonly, the lungs are affected, followed by the mucous membranes, skin, lymph nodes, and various internal organs.

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Epidemiology

Frequency

United States

The fungus is not endemic to the United States. A number of cases have been reported in patients who previously visited or resided in endemic areas.[3]

International

South American blastomycosis is restricted to Central America and South America, with about 80% of cases occurring in Brazil. About 6-50% of people living in endemic regions have positive paracoccidioidin skin test results, which indicate prior infection. Antibodies to P brasiliensis have been detected in 27% of blood donors in Brazil.[4, 5, 6, 7] Of the 90 million people living in endemic areas, approximately 10 million are infected, although exact figures are difficult to obtain.[8]

Mortality/Morbidity

  • The mortality rate is high for both the chronic adult and subacute juvenile forms if untreated. With treatment, the mortality rate is 7-10% for children and 1-10% for adults.[9]
  • In patients with HIV, the mortality rate is 30-45%.
  • Complications generally result from fibrotic scarring that occurs during healing. Patients can have residual chronic lung, oral, nasal, pharyngeal, and laryngeal problems after the lungs or mucous membranes heal. If internal organs, such as the adrenal glands, are affected, chronic organ dysfunction (ie, Addison disease) can develop.

Sex

  • The chronic adult form affects men more frequently than women, with a ratio of about 15:1. The fungus has receptors that bind estrogen. Binding of estrogen prevents the transformation of the mycelium into the yeast phase, which is necessary for tissue invasion. This inhibition has been hypothesized to explain the extreme sex differences despite the fact that equal numbers of men and women have positive paracoccidioidin skin test results and that equal numbers of prepubertal boys and girls have the subacute juvenile type.
  • The subacute juvenile form affects both sexes equally.

Age

  • Most patients are adult men aged 30-50 years.
  • Children are affected in only 3-5% of cases.
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Contributor Information and Disclosures
Author

Julie E Dixon, MD, FAAD  Private Practice, Ironwood Dermatology, Tucson, Arizona

Julie E Dixon, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Norman Levine  MD, Private practice, Tucson, AZ

Norman Levine is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Franklin Flowers, MD  Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, Affiliate Associate Professor of Pediatrics and Pathology, University of Florida College of Medicine

Franklin Flowers, MD, is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD  Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

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Crusted plaques over the central part of the face in a man with South American blastomycosis. Courtesy of Rolando Vasquez, MD, Professor of Dermatology, Guatemala.
Ulcerated nodule on the tongue in a man with South American blastomycosis. Courtesy of Heidi Logemann, Professor of Mycology, Universidad de San Carlos, Guatemala.
 
 
 
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