Blastomycosis Clinical Presentation
- Author: Chidinma Chima-Okereke, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
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,  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,  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.
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.
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.
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