Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Blastomycosis Clinical Presentation

  • Author: Chidinma Chima-Okereke, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
 
Updated: Feb 18, 2015
 

History

Patients with blastomycosis may present with any of several patterns of illness and 30-50% of persons infected may remain asymptomatic. A flulike illness with fever, chills, myalgia, headache, chest pain, and a nonproductive cough may occur, which resolves within days. Because of the brief and self-limited nature of these symptoms, blastomycosis may go undiagnosed except in the setting of a known outbreak. Alternatively, patients may present with an acute illness resembling bacterial pneumonia, with high fever, chills, a productive cough, and pleuritic chest pain; sputum is mucopurulent or purulent.

A chronic pneumonia may occur and simulate tuberculosis or lung cancer, with low-grade fever, a productive cough, night sweats, chest pain, and weight loss. Sputum is mucopurulent or purulent, and hemoptysis may be present. Often these patients receive multiple courses of antibiotics before the diagnosis is made.

Other patients, often older patients or those with immune compromise, may present with an acute rapidly progressive, severe disease. These cases manifest as acute respiratory distress syndrome (ARDS), with fever, shortness of breath, tachypnea, hypoxemia, and diffuse pulmonary infiltrates.

Extrapulmonary features may include the following:

  • Skin lesions – The skin is the second-most common site of spread after the lungs. The commonly seen skin manifestations are a purplish-gray verrucous lesions with heaped borders or friable lesions that ulcerate. Micro-abscesses and subcutaneous nodules can also be seen.
  • Bone lytic lesions – Seen in 25% of cases with extrapulmonary manifestations, [8] this may present with bone or joint pain, and soft-tissue swelling may be present. Osteomyelitis can involve any bone, although the lower spine and pelvis are most commonly affected. Contiguous spread of bone disease can result in deep abscesses or arthritis.
  • Genitourinary – Prostatitis, orchitis or epididymitis can be seen in men, [6] and rare cases of endometritis and tubo-ovarian abscess have been reported in women.
  • Central nervous system involvement – In 5-10% of cases, meningitis and intracranial or epidural abscesses may be seen. Cases of central diabetes insipidus have been reported from CNS blastomycosis.

Unusual sites of disseminated infection include the larynx (manifesting as hoarseness), uterus, reticuloendothelial system (liver, spleen, lymph nodes, bone marrow), oropharynx, nose, and thyroid.

Next

Physical Examination

The physical examination in patients with blastomycosis may not reveal any abnormal findings. In the pneumonic form, findings may be present that are associated with pneumonic consolidation (eg, dullness on percussion, bronchial breath sounds, egophony, rales). Decreased or absent breath sounds suggest pleural effusion.

Skin lesions are more common on the face, neck, and extremities. Early in the disease course, the lesions are sharply demarcated papules or pustules, or as subcutaneous nodules. Multiple lesions may appear simultaneously or in sequence.

Within a few weeks to months, the primary lesions evolve into ulcers, with indurated dusky or violaceous granulomatous or verrucous borders, or into vegetating plaques. (See the image below.) Typically, the border is arciform or serpiginous, contains numerous tiny pustules or microabscesses covered with crust, and rises abruptly from the normal surrounding skin.

Cutaneous blastomycosis. Cutaneous blastomycosis.

Over a period of months to years, the lesions enlarge, eventually involving a substantial portion of the face, for example, and produce severe disfigurement. As the lesions enlarge, they heal centrally, with atrophic scar studded with telangiectasia.

Although the vast majority of patients with cutaneous blastomycosis acquire it by dissemination from a pulmonary focus, a few well-documented cases of primary cutaneous (inoculation) blastomycosis have been described in laboratory workers. The skin lesions are described as "chancriform" and are accompanied by nodular lymphangitis.

Bone involvement rarely leads to a draining abscess. The involved joint may be tender and swollen.

Previous
 
 
Contributor Information and Disclosures
Author

Chidinma Chima-Okereke, MD Fellow in Pulmonary and Critical Care Medicine, Lung Institute, Cedars Sinai Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases,Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Michael Peterson, MD Chief of Medicine, Vice-Chair of Medicine, University of California, San Francisco, School of Medicine; Endowed Professor of Medicine, University of California, San Francisco-Fresno, School of Medicine

Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Mark R Schleiss, MD Minnesota American Legion and Auxiliary Heart Research Foundation Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Avinash Shetty, MD Department of Pediatrics, Division of Pediatric Infectious Diseases, Assistant Professor of Pediatrics, Wake Forest University School of Medicine

Avinash Shetty, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Basil Varkey, MD, FCCP Professor Emeritus, Department of Internal Medicine, Division of Pulmonary and Critical Care, Medical College of Wisconsin; Consulting Pulmonologist, Froedtert Memorial Lutheran Hospital

Basil Varkey, MD, FCCP is a member of the following medical societies: American Association of Physicians of Indian Origin and American College of Chest Physicians

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Pappas PG, Pottage JC, Powderly WG, Fraser VJ, Stratton CW, McKenzie S, et al. Blastomycosis in patients with the acquired immunodeficiency syndrome. Ann Intern Med. 1992 May 15. 116(10):847-53. [Medline].

  2. Martynowicz MA, Prakash UB. Pulmonary blastomycosis: an appraisal of diagnostic techniques. Chest. 2002 Mar. 121(3):768-73. [Medline].

  3. Chapman SW, Dismukes WE, Proia LA, et al. Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2008 Jun 15. 46(12):1801-12. [Medline].

  4. Rooney PJ, Sullivan TD, Klein BS. Selective expression of the virulence factor BAD1 upon morphogenesis to the pathogenic yeast form of Blastomyces dermatitidis: evidence for transcriptional regulation by a conserved mechanism. Mol Microbiol. 2001 Feb. 39(4):875-89. [Medline].

  5. Chapman SW, Lin AC, Hendricks KA, et al. Endemic blastomycosis in Mississippi: epidemiological and clinical studies. Semin Respir Infect. 1997 Sep. 12(3):219-28. [Medline].

  6. Sarosi GA, Eckman MR, Davies SF, Laskey WK. Canine blastomycosis as a harbinger of human disease. Ann Intern Med. 1979 Nov. 91(5):733-5. [Medline].

  7. Hay RJ. Blastomycosis: what's new?. J Eur Acad Dermatol Venereol. 2000 Jul. 14(4):249-50. [Medline].

  8. Bradsher RW. Histoplasmosis and blastomycosis. Clin Infect Dis. 1996 May. 22 Suppl 2:S102-11. [Medline].

  9. Klein BS, Vergeront JM, Weeks RJ, Kumar UN, Mathai G, Varkey B, et al. Isolation of Blastomyces dermatitidis in soil associated with a large outbreak of blastomycosis in Wisconsin. N Engl J Med. 1986 Feb 27. 314(9):529-34. [Medline].

  10. Pfaller MA, Diekema DJ. Epidemiology of invasive mycoses in North America. Crit Rev Microbiol. 2010. 36(1):1-53. [Medline].

  11. Chu JH, Feudtner C, Heydon K, Walsh TJ, Zaoutis TE. Hospitalizations for endemic mycoses: a population-based national study. Clin Infect Dis. 2006 Mar 15. 42(6):822-5. [Medline].

  12. Carlos WG, Rose AS, Wheat LJ, et al. Blastomycosis in indiana: digging up more cases. Chest. 2010 Dec. 138(6):1377-82. [Medline].

  13. Baumgardner DJ, Buggy BP, Mattson BJ, Burdick JS, Ludwig D. Epidemiology of blastomycosis in a region of high endemicity in north central Wisconsin. Clin Infect Dis. 1992 Oct. 15(4):629-35. [Medline].

  14. Frean JA, Carman WF, Crewe-Brown HH, Culligan GA, Young CN. Blastomyces dermatitidis infections in the RSA. S Afr Med J. 1989 Jul 1. 76(1):13-6. [Medline].

  15. Baily GG, Robertson VJ, Neill P, Garrido P, Levy LF. Blastomycosis in Africa: clinical features, diagnosis, and treatment. Rev Infect Dis. 1991 Sep-Oct. 13(5):1005-8. [Medline].

  16. Anjorin FI, Kazmi R, Malu AO, Lawande RV, Fakunle YM. A case of blastomycosis from Zaria, Nigeria. Trans R Soc Trop Med Hyg. 1984. 78(5):577-80. [Medline].

  17. Jerray M, Hayouni A, Benzarti M, Klabi N, Garrouche A. Blastomycosis in Africa: a new case from Tunisia. Eur Respir J. 1992 Mar. 5(3):365-7. [Medline].

  18. Ferchichi L, Mekni A, Bellil K, Haouet S, Zeddini A, Bellil S, et al. [Three cases of cutaneous blastomycosis]. Med Mal Infect. 2006 May. 36(5):285-7. [Medline].

  19. Rais H, Jghaimi F, Baalal H, Naji Y, Essaadouni L, Essadki O, et al. [Blastomycosis in Morocco: imported mycosis]. Rev Pneumol Clin. 2012 Feb. 68(1):45-9. [Medline].

  20. Roy M, Benedict K, Deak E, Kirby MA, McNiel JT, Sickler CJ, et al. A large community outbreak of blastomycosis in Wisconsin with geographic and ethnic clustering. Clin Infect Dis. 2013 Sep. 57(5):655-62. [Medline].

  21. Cano MV, Ponce-de-Leon GF, Tippen S, Lindsley MD, Warwick M, Hajjeh RA. Blastomycosis in Missouri: epidemiology and risk factors for endemic disease. Epidemiol Infect. 2003 Oct. 131(2):907-14. [Medline].

  22. Centers for Disease Control and Prevention (CDC). Blastomycosis--Wisconsin, 1986-1995. MMWR Morb Mortal Wkly Rep. 1996 Jul 19. 45(28):601-3. [Medline].

  23. Pfister JR, Archer JR, Hersil S, Boers T, Reed KD, Meece JK, et al. Non-rural point source blastomycosis outbreak near a yard waste collection site. Clin Med Res. 2011 Jun. 9(2):57-65. [Medline]. [Full Text].

  24. Kaplan W, Clifford MK. Blastomycosis. I. A review of 198 collected cases in veterans administration hospitals. Am Rev Respir Dis. 1964 May. 89:659-72. [Medline].

  25. Varkey B. Blastomycosis in children. Semin Respir Infect. 1997 Sep. 12(3):235-42. [Medline].

  26. Schutze GE, Hickerson SL, Fortin EM, Schellhase DE, Darville T, Gubbins PO, et al. Blastomycosis in children. Clin Infect Dis. 1996 Mar. 22(3):496-502. [Medline].

  27. Pappas PG, Threlkeld MG, Bedsole GD, Cleveland KO, Gelfand MS, Dismukes WE. Blastomycosis in immunocompromised patients. Medicine (Baltimore). 1993 Sep. 72(5):311-25. [Medline].

  28. Lemos LB, Baliga M, Guo M. Blastomycosis: The great pretender can also be an opportunist. Initial clinical diagnosis and underlying diseases in 123 patients. Ann Diagn Pathol. 2002 Jun. 6(3):194-203. [Medline].

  29. Conces DJ Jr. Endemic fungal pneumonia in immunocompromised patients. J Thorac Imaging. 1999 Jan. 14(1):1-8. [Medline].

  30. Meyer KC, McManus EJ, Maki DG. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. N Engl J Med. 1993 Oct 21. 329(17):1231-6. [Medline].

  31. Durkin M, Witt J, Lemonte A, Wheat B, Connolly P. Antigen assay with the potential to aid in diagnosis of blastomycosis. J Clin Microbiol. 2004 Oct. 42(10):4873-5. [Medline]. [Full Text].

  32. Bialek R, Cirera AC, Herrmann T, Aepinus C, Shearn-Bochsler VI, Legendre AM. Nested PCR assays for detection of Blastomyces dermatitidis DNA in paraffin-embedded canine tissue. J Clin Microbiol. 2003 Jan. 41(1):205-8. [Medline]. [Full Text].

  33. Dismukes WE, Bradsher RW Jr, Cloud GC, Kauffman CA, Chapman SW, George RB, et al. Itraconazole therapy for blastomycosis and histoplasmosis. NIAID Mycoses Study Group. Am J Med. 1992 Nov. 93(5):489-97. [Medline].

  34. Dismukes WE, Cloud G, Bowles C. Treatment of blastomycosis and histoplasmosis with ketoconazole. Results of a prospective randomized clinical trial. National Institute of Allergy and Infectious Diseases Mycoses Study Group. Ann Intern Med. 1985 Dec. 103(6 ( Pt 1)):861-72. [Medline].

  35. Pappas PG, Bradsher RW, Chapman SW, Kauffman CA, Dine A, Cloud GA, et al. Treatment of blastomycosis with fluconazole: a pilot study. The National Institute of Allergy and Infectious Diseases Mycoses Study Group. Clin Infect Dis. 1995 Feb. 20(2):267-71. [Medline].

  36. Ta M, Flowers SA, Rogers PD. The role of voriconazole in the treatment of central nervous system blastomycosis. Ann Pharmacother. 2009 Oct. 43(10):1696-700. [Medline].

  37. Bariola JR, Perry P, Pappas PG, Proia L, Shealey W, Wright PW, et al. Blastomycosis of the central nervous system: a multicenter review of diagnosis and treatment in the modern era. Clin Infect Dis. 2010 Mar 15. 50(6):797-804. [Medline].

  38. Lentnek AL, Lentek IA. Successful management of Blastomyces dematitidis meningitis. Infect Med. 2006. 23:39.

  39. Lutsar I, Roffey S, Troke P. Voriconazole concentrations in the cerebrospinal fluid and brain tissue of guinea pigs and immunocompromised patients. Clin Infect Dis. 2003 Sep 1. 37(5):728-32. [Medline].

  40. Wuthrich M, Warner T, Klein BS. IL-12 is required for induction but not maintenance of protective, memory responses to Blastomyces dermatitidis: implications for vaccine development in immune-deficient hosts. J Immunol. 2005 Oct 15. 175(8):5288-97. [Medline].

  41. Crampton TL, Light RB, Berg GM, Meyers MP, Schroeder GC, Hershfield ES. Epidemiology and clinical spectrum of blastomycosis diagnosed at Manitoba hospitals. Clin Infect Dis. 2002 May 15. 34(10):1310-6. [Medline].

 
Previous
Next
 
Cutaneous blastomycosis.
Lateral chest radiograph reveals the ill-defined lingular opacity and an absence of pleural effusions.
Composite photomicrograph of a tissue specimen from a patient with blastomycosis infection shows an abundance of large budding cells that had been configured in chains. Courtesy of CDC/Dr. Lucille K. George.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.