eMedicine Specialties > Radiology > Chest

Blastomycosis, Thoracic: Imaging

Author: Fahad M Alhameed, MD, AmBIM, FCCP, FRCPC, Deputy Chairman of Intensive Care Department, Consultant Critical Care and Pulmonary Medicine, Department of Intensive Care and Pulmonary Medicine, King Khalid National Guard Hospital, Jeddah, Saudi Arabia
Coauthor(s): Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital; Bruce Maycher, MD, Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor, Department of Radiology, University of Manitoba
Contributor Information and Disclosures

Updated: Oct 17, 2008

Radiography

Findings

  • Chest radiographs usually reveal focal lung opacities in the upper lobes (seen in 25-75% of patients); these opacities are often nodular in character. In adults, the upper lobes are affected more frequently than the lower lobes; the ratio is approximately 2:1. In children, opacities most commonly involve the lower lobes. Lung opacities may be patchy or confluent; they may be subsegmental, segmental, or nonsegmental (see Images 1-2). The radiographic appearance is similar to that seen with community acquired pneumonia; slow improvement, lack of change, or even progression of disease over time should raise the possibility of granulomatous infection (see Images 3-4).
  • The next most common radiographic presentation (occurring in as many as 30% of patients) is that of a focal discrete mass, either single or multiple. The mass is usually well circumscribed; such masses are variable in size and occasionally contain air-bronchograms. When solitary, a mass may mimic primary carcinoma, especially when associated with unilateral lymph node enlargement or bone destruction (see Images 5-6).
  • Cavitation occurs less commonly in patients with blastomycosis than in patients with tuberculosis or chronic histoplasmosis; the reported incidence is approximately 15-20% (see Images 8-9).
  • In a minority of patients, a miliary or diffuse interstitial disease pattern is seen at presentation; patients have respiratory failure and need mechanical ventilation. This pattern may be observed in previously healthy immunocompromised patients. In many patients, the focal lung opacities or mass may be observed in association with the diffuse interstitial pattern — a finding that supports the hypothesis that pulmonary dissemination occurs from a focal pulmonary site (see Image 10).
  • In contrast to histoplasmosis, hilar and mediastinal adenopathy and calcification are uncommon (occurring in 10-20% of cases) (see Image 10).
  • Pleural involvement and significant effusion are uncommon (20%). Rarely, lung or pleural involvement extends into adjacent bones or soft tissues. Pleural thickening without free effusion is a more common radiographic finding.
  • Osteolytic lesions in the skeleton usually are associated with superficial abscesses.
  • Rarely, mediastinal involvement results in superior vena cava obstruction or brachial plexopathy.

Computed Tomography

Findings

CT findings of thoracic blastomycosis are variable. As with chest radiography, nonspecific lung parenchymal opacification is most commonly observed, followed by mass lesions (see Images 3-4). In a review of CT findings in 16 patients with pulmonary blastomycosis, Winer-Muram et al reported the following20 :

  • A localized mass was observed in 14 patients (88%).
  • Consolidation was observed in 9 patients (56%).
  • Masses ranged from 3-16 cm in diameter (mean, 8 cm).
  • Most masses contained air bronchograms (12 of 14 patients [86%]) (see Image 7).
  • In 11 patients, abnormalities were unilateral; in 5, they involved both lungs.
  • No lobar predominance was noted.
  • Cavitation was observed in 2 patients (see Image 9); calcified hilar nodes was observed in 7 patients (44%); and enlarged noncalcified nodes was observed in 1 patient.

More on Blastomycosis, Thoracic

Overview: Blastomycosis, Thoracic
Imaging: Blastomycosis, Thoracic
Follow-up: Blastomycosis, Thoracic
Multimedia: Blastomycosis, Thoracic
References
Further Reading
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References

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  7. Wisconsin Department of Health Services. RARE FUNGAL INFECTION CAN GO UNDIAGNOSED. Last revised Sept. 12, 2008. Wisconsin Department of Health Services. Available at http://dhs.wisconsin.gov/News/PressReleases/2008/091208Blasto.htm. Accessed October 17, 2008.

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Further Reading

Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America.
Infectious Diseases Society of America.  2000 Apr (revised 2008 Jun 15).  12 pages.  NGC:006497

Coccidioidomycosis.
Infectious Diseases Society of America.  2000 Apr (revised 2005 Nov 1).  7 pages.  NGC:004563 

Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America.
Infectious Diseases Society of America.  2000 Apr (revised 2007 Oct).  19 pages.  NGC:005950 
 

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Keywords

blastomycosis, thoracic blastomycosis, Blastomyces dermatitidis, pulmonary blastomycosis, disseminated blastomycosis, blastomycetoma, blastocytoma, Gilchrist disease, mycosis, mycoses

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Contributor Information and Disclosures

Author

Fahad M Alhameed, MD, AmBIM, FCCP, FRCPC, Deputy Chairman of Intensive Care Department, Consultant Critical Care and Pulmonary Medicine, Department of Intensive Care and Pulmonary Medicine, King Khalid National Guard Hospital, Jeddah, Saudi Arabia
Fahad M Alhameed, MD, AmBIM, FCCP, FRCPC is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Bruce Maycher, MD, Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor, Department of Radiology, University of Manitoba
Bruce Maycher, MD is a member of the following medical societies: American Roentgen Ray Society, Canadian Medical Association, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

Medical Editor

Satinder P Singh, MD, Associate Professor of Radiology, Chief of Cardiopulmonary Radiology, Director of Cardiac CT, Director of Combined Cardiopulmonary and Abdominal Radiology, Department of Radiology, University of Alabama at Birmingham
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Eric J Stern, MD, Professor of Radiology, Adjunct Professor of Medicine, Adjunct Professor of Medical Education and Biomedical Informatics, University of Washington School of Medicine; Director of Thoracic Imaging, Harborview Medical Center; Associate Medical Staff, Seattle Cancer Care Alliance
Eric J Stern, MD is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, European Society of Radiology, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Clinical Assistant Professor of Radiology, University of Washington Medical School
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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