Blastomycosis Clinical Presentation

  • Author: Basil Varkey, MD, FCCP; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Feb 8, 2011
 

History

Most symptoms conform to one of the following patterns of respiratory illness:

  • A flulike illness with fever, chills, myalgia, headache, 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.
  • The patient may present with an acute illness resembling bacterial pneumonia, with symptoms of high fever, chills, a productive cough, and pleuritic chest pain. Sputum is mucopurulent or purulent.
  • Chronic illness may occur and simulate tuberculosis or lung cancer, with symptoms of low-grade fever, a productive cough, night sweats, and weight loss. Sputum is mucopurulent or purulent, and hemoptysis may be present.
  • The patient may present with a fast, progressive, and severe disease that manifests as ARDS, with fever, shortness of breath, tachypnea, hypoxemia, and diffuse pulmonary infiltrates.

Skin lesions, although usually asymptomatic, may be the presenting complaint. Bone lytic lesions cause bone or joint pain. Soft tissue swelling may be present. Although reported cases suggest vertebrae and pelvis as the common sites, it should be noted that any bone can be involved. Prostatitis may be asymptomatic or may cause pain on urinating. Laryngeal involvement causes hoarseness.

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Physical

The physical examination 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. Occasionally, erythema nodosum may be observed in association with pulmonary blastomycosis.

Skin lesions are more common on the face, neck, and extremities. Early in the disease course, the lesions are sharply demarcated papules. Later, they expand to form ulcerated lesions with small pustules at the margins. Central healing and scar formation occur as the lesions grow larger. Some are verrucous, with raised irregular borders; multiple lesions may appear simultaneously or in sequence.

Lesions begin as papules or pustules or as subcutaneous nodules. 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. Typically, the border is arciform or serpiginous, contains numerous tiny pustules or microabscesses covered with crust, and rises abruptly from the normal surrounding skin. 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.

Note the image below.

Cutaneous blastomycosis. Cutaneous blastomycosis.

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

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Specialty Editor Board

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.

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

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

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

Disclosure: Nothing to disclose.

References

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  3. 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. Feb 27 1986;314(9):529-34. [Medline].

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

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

  11. 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. Jan 2003;41(1):205-8. [Medline]. [Full Text].

  12. 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. Jun 15 2008;46(12):1801-12. [Medline].

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

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

  15. 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. Oct 15 2005;175(8):5288-97. [Medline].

 
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