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Blastomycosis is a pulmonary disease caused by inhaling spores of the dimorphic fungus Blastomyces dermatitidis; occasionally, the fungi spread hematogenously, causing extrapulmonary disease. Symptoms result from pneumonia or from dissemination to multiple organs, most commonly the skin. Diagnosis is clinical, by chest x-ray, or both and is confirmed by laboratory identification of the fungi. Treatment is with itraconazole, fluconazole, or amphotericin B.
(See also the Infectious Diseases Society of America's Practice Guidelines for the Management of Patients with Blastomycosis.)
In North America, the endemic area for blastomycosis includes
Infection also occurs in the Middle East and Africa.
Immunocompetent people can contract this infection. Although blastomycosis may be more common and more severe in immunocompromised patients, it is a less common opportunistic infection than histoplasmosis or coccidioidomycosis.
B. dermatitidis grows as a mold at room temperature in soil enriched with animal excreta and in moist, decaying, acidic organic material, often near rivers. In the lungs, inhaled spores convert into large (15 to 20 μm) invasive yeasts, which form characteristic broad-based buds.
Once in the lungs, infection may
Hematogenous dissemination can cause focal infection in numerous organs, including the skin, prostate, epididymides, testes, kidneys, vertebrae, ends of long bones, subcutaneous tissues, brain, oral or nasal mucosa, thyroid, lymph nodes, and bone marrow.
Symptoms and Signs
Pulmonary:
Pulmonary blastomycosis may be asymptomatic or cause an acute, self-limited disease that often goes unrecognized. It can also begin insidiously and develop into a chronic, progressive infection. Symptoms include a productive or dry hacking cough, chest pain, dyspnea, fever, chills, and drenching sweats.
Pleural effusion occurs occasionally. Some patients have rapidly progressive infections, and acute respiratory distress syndrome may develop.
Extrapulmonary:
In extrapulmonary disseminated blastomycosis, symptoms depend on the organ involved. Skin lesions are by far the most common; they may be single or multiple and may occur with or without clinically apparent pulmonary involvement. Papules or papulopustules usually appear on exposed surfaces and spread slowly. Painless miliary abscesses, varying from pinpoint to 1 mm in diameter, develop on the advancing borders. Irregular, wartlike papillae may form on surfaces. As lesions enlarge, the centers heal, forming atrophic scars. When fully developed, an individual lesion appears as an elevated verrucous patch, usually ≥ 2 cm wide with an abruptly sloping, purplish red, abscess-studded border. Ulceration may occur if bacterial superinfection is present.
If bone lesions develop, overlying areas are sometimes swollen, warm, and tender. Genital lesions cause painful epididymal swelling, deep perineal discomfort, or prostatic tenderness detected during rectal examination.
Diagnosis
A chest x-ray should be taken. Focal or diffuse infiltrates may be present, sometimes as patchy bronchopneumonia fanning out from the hilum. These findings must be distinguished from other causes of pneumonia (eg, other mycoses, TB, tumors). Skin lesions can be mistaken for sporotrichosis, TB, iodism, or basal cell carcinoma. Genital involvement may mimic TB.
Cultures of infected material are done; they are definitive when positive. The organism's characteristic appearance, seen during microscopic examination of tissues or sputum, is also frequently diagnostic. Serologic testing is not sensitive but is useful if positive.
Treatment
Untreated blastomycosis is usually slowly progressive and is rarely ultimately fatal. Treatment depends on severity of the infection. For mild to moderate disease, itraconazole 200 to 400 mg po once/day is used. Fluconazole appears less effective, but 400 to 800 mg po once/day may be tried in itraconazole-intolerant patients with mild disease. For severe, life-threatening infections, IV amphotericin B is usually effective.
Voriconazole and posaconazole are highly active against B. dermatitidis, but their role has not yet been defined.
Last full review/revision April 2009 by Alan M. Sugar, MD
Content last modified April 2009
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