A 53‐year‐old white man from Chicago presented with complaints of dysuria followed by right testicular pain and swelling, multiple painful skin lesion, productive cough, right middle finger painful swelling and significant weight loss for 6 months. He had several weeks of oral antibiotics without improvement. On examination, he was afebrile, chest was clear to auscultation, the skin lesions were erythematous, slightly raised, tender, 5‐mm macules. Right testicle was enlarged, very hard and firm, very tender to palpation. Right middle finger was sausage‐shaped and tender to palpation. The proximal interphalangeal joint was swollen tender and had limited range of motion. He was anemic, white cell count was 12,900. CT chest showed bilateral diffuse reticular nodular opacities. Incidentally, MRI of the brain showed multiple diffuse 5‐mm enhancing lesions with minimal surrounding edema. Testicular ultrasound was consistent with epididymitis and orchitis. X‐rays of right middle finger showed significant joint destruction with loss of the joint space suggestive of septic arthritis. Transbronchial lung biopsy showed mild organizing pneumonia with small poorly formed noncaseating granuloma with large yeast forms. Skin biopsy and bronchoalveolar lavage grew broad based budding yeast identified as Blastomyces dermatitidis. HIV serology was negative. IgG, IgM, and IgA were within normal range. He was given IV amphotericin B for 2 weeks, then itraconazole for the next 12 months. He improved clinically and repeat MRI of the brain done 10 weeks later showed marked improvement in the brain lesion.
Blastomycosis is an uncommon disease caused by the dimorphic fungus Blastomyces dermatitidis. It can manifest as chronic pulmonary symptoms or disseminated disease. Dissemination occurs in two thirds of the cases. This patient has a very widespread dissemination to the skin, lung, joint, testes, and brain. Dissemination to the brain is rare in immunocompetent patients. Spontaneous cures may occur in some immunocompetent individuals with acute pulmonary blastomycosis . All patients who are immunocompromised, have progressive pulmonary disease, or have extrapulmonary disease must be treated. Treatment options include amphotericin B, ketoconazole, itraconazole, and fluconazole. Amphotericin B is the treatment of choice for patients who are pregnant, immunocompromised, have life‐threatening or central nervous system (CNS) disease, or for whom azole treatment has failed. Itraconazole is the initial treatment of choice for non‐life‐threatening non‐CNS blastomycosis.
Disseminated blastomycosis is an uncommon disease, and dissemination to the brain is rare in immunocompetent host. Treatment option is based on immune status and presence of CNS disease.
To cite this abstract:Ugbarugba E. A Case of Disseminated Blastomycosis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 336. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-case-of-disseminated-blastomycosis/. Accessed April 4, 2020.