First Japanese case of disseminated blastomycosis imported from North America: A case report

Blastomycosis is a fungal infectious disease that can occur in both immunocompromised and immunocompetent populations endemic in North America, with no previous reports in Japan. A 26-year-old Japanese female patient with no relevant medical history presented intermittent left back pain and an abnormal shadow in the left upper lung field eight months ago at a local clinic. She was referred to our hospital for further evaluation and treatment. The patient currently lives in Japan, but until two years ago had spent several years in New York, Vermont and California. Chest computed tomography revealed a 30 mm mass with a cavity in the left pulmonary apex. The specimens obtained by transbronchial biopsy showed periodic acid-Schiff stain (PAS)-positive and Grocott-positive yeast-like fungi scattered among the granulomas, with no malignant findings, and the initial pathology did not lead to a definitive diagnosis. She was empirically started on fluconazole because of onset of multiple subcutaneous abscesses and was referred to the Medical Mycology Research Center. Although antibody tests could not diagnose the disease, blastomycosis was suspected based on the pathology of the skin and lung tissue at the Medical Mycology Research Center, and Blastomyces dermatitidis was identified by ITS analysis of the rRNA region. Her symptoms and CT findings gradually improved with fluconazole. We reported the first Japanese case of blastomycosis with pulmonary and cutaneous involvement in Japan. As the number of overseas travelers is expected to continue increasing, we would like to emphasize the importance of travel history interviews and information of blastomycosis.

Fungal infections in solid organ transplantation

Fungal infections in solid organ transplant recipients continue to be a significant cause of morbidity and mortality. Candida spp. and Aspergillus spp. account for most invasive fungal infections. The incidence of fungal infection varies with type of solid organ transplant. Liver transplant recipients have highest reported incidence of candida infections while lung transplant recipients have highest rate of Aspergillus infections. Recent epidemiological studies suggest the emergence of resistant strains of candida as well as mycelial fungi other than Aspergillus in these patients. The current review incorporates the recent changes in the epidemiology of fungal infections in solid organ transplant recipients and highlights the newer data on the diagnosis, prophylaxis and treatment of fungal infections in these patients.

Symptoms of pulmonary blastomycosis: northern Wisconsin, United States

OBJECTIVE

Pulmonary disease is the most common manifestation of the systemic fungal infection, blastomycosis. This study examines symptoms of pulmonary blastomycosis and possible age and gender differences in a 22-year case series.

METHODS

Laboratory-confirmed cases of blastomycosis were identified from mandatory reports to the Vilas County Health Department (1984--2001) and from hospital records and case contacts before mandated reports (November 1979--1983). Symptoms were ascertained by interviews of respondent cases (or next of kin) by using a standard form. Proportions were compared with the chi-square test or Fisher exact test.

RESULTS

One hundred seventy cases of blastomycosis (mean age 44, 56% male) were identified and pulmonary manifestations were present in 154 (91%). Of the 118 interviewed cases, the following symptoms were common: cough (90%), fever (75%), night sweats (68%), weight loss (66%), chest pain (63%), dyspnea (54%), and aches (50%). Hemoptysis occurred in 18%, and nearly all queried patients had fatigue. The dyad of cough and fever occurred in 73%, and triads of fever-cough-night sweats, fever-cough-weight loss, and fever-cough-chest pain occurred in 58%, 57%, and 51%, respectively. Among men, fever (P = .03), cough and fever (P = .03), fever-cough-weight loss (P = .03), and fever-cough-night sweats (P = .03) were less common in those 50 years of age and older. Symptoms did not vary by duration of illness.

CONCLUSIONS

Cough, fever, night sweats, weight loss, chest pain, dyspnea, and aches are common symptoms of pulmonary blastomycosis. Symptom constellations that included fever were less common in men 50 years of age and older. There was no apparent difference in symptoms between acute and chronic blastomycosis.

Cutaneous blastomycosis presenting as non-healing ulcer and responding to oral ketoconazole

Primary cutaneous blastomycosis is a rare infection of the skin that usually follows trauma and presents as a papule or nodule that ulcerates. Although this infection often heals spontaneously, we present a case of a nonhealing ulcer following surgical drainage of cellulitis. Blastomycosis was diagnosed by histopathological examination and the infection responded well to oral ketoconazole therapy.

Cluster of pulmonary blastomycosis in a rural community: evidence for multiple high-risk environmental foci following a sustained period of diminished precipitation

Much of our understanding of the epidemiologic features of infection with Blastomyces dermatitidis has come from cluster and outbreak investigations which have established the association of human disease with recreational pursuits and the presence of infectious microfoci in areas of moist soil with high organic content. This report describes the clustering of eight cases of pulmonary blastomycosis without an apparent common source exposure which occurred during a 90 day period in a 96 square mile area (population 4,450) within Oconto County, Wisconsin. We conclude that multiple high-risk environmental foci may have existed following a sustained five-year period of diminished precipitation in the cluster area. A case-control study which included family and community controls concluded that multiple earth-disturbing activities engaged in by case-patients was statistically associated with illness. Lymphocyte-proliferation assays of whole blood samples detected previously unrecognized infection with B. dermatititidis among five of 32 family controls.

Using new genetic tools to study the pathogenesis of Blastomyces dermatitidis

Fungal pathogens have emerged as a public health menace owing to the expanding population of vulnerable patients and a heightened exposure to fungi in our environment, particularly for the systemic dimorphic fungi that inhabit soil worldwide. A better understanding of these invaders and their pathogenic mechanisms is badly needed to further research into therapeutic options. Advances in the molecular tools available for genetic manipulation of Blastomyces dermatitidis have enhanced our ability to study this poorly understood dimorphic fungal pathogen. Recent refinements in gene-transfer techniques, new selection markers, reliable reporter fusions and successes in gene targeting have shed light upon the importance of the mycelium-to-yeast transition and the crucial and complex role the BAD1 adhesin plays in pathogenesis.

Blastomycosis: organ involvement and etiologic diagnosis. A review of 123 patients from Mississippi

Blastomycosis can only be diagnosed through the identification of the yeasts of Blastomyces dermatitidis in body fluids, tissues, or cultured material. The charts from 123 patients treated for blastomycosis at the University of Mississippi Medical Center from January 1980 through May 2000 were reviewed to determine the role of wet preparation, cytology, histology, and culture in diagnosing this fungal disease. Cytology uncovered the etiologic agent in 56.1% of all cases and in 71.8% of pulmonary cases. Cytology also was the first method to disclose the fungus in 57.7% of pulmonary cases. Sputum was the cytology specimen examined in 51% of the patients. In 69 patients with lung involvement, pulmonary cytology was positive in 97% of cases. Wet preparation was the second method to most commonly uncover the fungus in 37.4% of all cases. Histology was the third method with 32.5% of positive cases. Cultures were positive in 64.2% of all cases but they were the first to detect the fungus in only 3.2% of all patients. There was pulmonary involvement in 87% of patients, cutaneous involvement in 20%, osseous involvement in 15%, and central nervous involvement in 3%. In the medical literature the relative proportion of pulmonary versus disseminated disease clearly increased in series reported after 1959. Proportionally to the pattern of patients admitted to the University of Mississippi Medical Center, there is a clear predominance of black males among patients with blastomycosis followed by black females. White females constitute the sex/ethnic group least affected by this fungal disease.

Blastomycosis acquired occupationally during prairie dog relocation--Colorado, 1998

On August 31, 1998, two suspected cases of fungal pneumonia were reported to the Boulder County (Colorado) Health Department (BCHD). Both patients were immunocompetent, otherwise healthy adults working for the City of Boulder Open Space (CBOS) program on a prairie dog relocation project. This report summarizes the epidemiologic investigation by BCHD, the Colorado Department of Public Health and Environment, and CDC; the findings indicate that these two persons acquired blastomycosis in Colorado, which is outside the area where the disease is endemic.

Role of cell-surface molecules of Blastomyces dermatitidis in host-pathogen interactions

The fungal pathogen Blastomyces dermatitidis produces an adhesin (WI-1) in yeast stages, which contains repetitive regions that bind host-cell receptors. Adhesin and glucan may modulate fungal interactions with macrophages; their level of expression is altered in hypovirulent mutants. Adhesin is also involved in immune responses, and may be important in eliciting the clearance of the fungus.

Histoplasmosis and blastomycosis

Histoplasmosis and blastomycosis are caused by dimorphic fungi, can be epidemic or endemic, and can produce a spectrum of illness, from subclinical infection to progressive disseminated disease. Diagnosis of both is best made by visualization of yeast in tissue or by culture. Itraconazole is the drug of choice for treatment of both histoplasmosis and blastomycosis, except in cases of life-threatening infection, for which amphotericin B is indicated. A heavy inoculum of Histoplasma capsulatum may cause acute pulmonary infection in an otherwise healthy host, resulting in fever, hypoxia, and pulmonary infiltrates. Opportunistic histoplasmosis develops as chronic pulmonary histoplasmosis in those with a structural defect in the lung (emphysema) or as disseminated histoplasmosis in patients with cellular immune deficiency (due to immunosuppressants or AIDS). Blastomyces dermatitidis causes both pulmonary and extrapulmonary disease. Lung involvement may mimic bacterial pneumonia, while chronic presentations mimic lung cancer or tuberculosis. Skin is the most common extrapulmonary site of disease, followed by bone, prostate, and central nervous system.

Cutaneous manifestations of systemic mycoses

Systemic fungal diseases are primary pulmonary diseases caused by the dimorphic fungal pathogens, Blastomyces dermatitides, Coccidioides immitis. Histoplasma capsulatum, or Paracoccidioides brasiliensis. Infection occurs after inhalation of the infectious form of the fungus and may be acute, self-limited, or subclinical. Primary cutaneous infection occurs only after traumatic implantation of the fungus and is unusual. Erythema nodosum or erythema multiforme may accompany the acute form of the disease. Other cutaneous manifestations represent disseminated disease and, as such, require systemic antifungal therapy. Because cutaneous lesions have occurred coincidentally with other cutaneous pathologies, emphasis should be placed on a complete clinical history, physical examination, and diagnosis by histopathology and culture.

Blastomycosis of the eyelid

BACKGROUND

Published reports indicate that eyelid involvement occurs in approximately 25% of patients with systemic blastomycosis and that mortality exceeds 60% in untreated patients. The purpose of this study is to investigate this purportedly frequent association.

METHODS

The Medical Diagnostic index of the Mayo Clinic was used to identify patients who were treated for blastomycosis from 1976 through 1993. The medical records of affected patients were reviewed.

RESULTS

Of 79 patients with blastomycosis, only 1 (1.27%; 95% confidence interval, 0.03%-6.85%) had eyelid involvement. The diagnosis of systemic disease was established in this patient after biopsy of the eyelid lesion, and the infection responded satisfactorily to treatment with itraconazole.

CONCLUSION

Contrary to previous reports, eyelid involvement with systemic blastomycosis is uncommon.

Brain abscess caused by Blastomyces dermatitidis in a child with cystic fibrosis

An 8-year-old girl with moderately severe cystic fibrosis and right upper lobe bronchiectasis developed a cerebellar abscess caused by Blastomyces dermatitidis. To our knowledge, this is the youngest child with cystic fibrosis and a brain abscess, and the first documented case caused by a fungus.

Blastomycosis and human immunodeficiency virus: three new cases and review

Reports of blastomycosis in individuals infected with the human immunodeficiency virus (HIV) are increasing. We report on 3 patients co-infected with blastomycosis and HIV (to add to the previously reported 21), and review important clinical aspects and outcomes in all cases. The percentage of patients co-infected with blastomycosis and HIV who had disseminated blastomycosis (63%) was similar to the blastomycosis patients in the general population (67%); however, as a group the patients with HIV were severely immunosuppressed and fared poorly. Severe immunodeficiency was indicated by CD4 counts < 200/mm3 in 85% of co-infected patients. Central nervous system (CNS) involvement occurred in 46% of this group, approximately 5 to 10 times more frequently than in individuals not infected with HIV previously reported at 5% to 10%. The mortality rate from blastomycosis for patients with both HIV infection and blastomycosis is 54%, about 5 times the mortality rate of blastomycosis patients in the general population, previously reported at < 10%. Disseminated blastomycosis in individuals with HIV may appear as deep cutaneous ulcers, as was the case in two of our patients. Although blastomycosis is not an AIDS-defining infection, it may be reasonable to consider HIV testing and measurement of CD4 counts in patients with blastomycosis. Such testing could help identify individuals who are HIV positive but asymptomatic who have blastomycosis, as well as provide useful information regarding a possible association between CD4 cell deficiency and various clinical manifestations of blastomycosis. Patients with HIV and blastomycosis should be examined carefully for any evidence of CNS involvement. Lifetime therapy with ketoconazole or itraconazole is likely to be of benefit to patients with HIV who have been treated successfully for blastomycosis.

Blastomycosis in transplant recipients: report of a case and review

Fungi cause serious, often fatal infections in immunocompromised hosts. Recipients of solid organ and bone marrow transplants are predisposed to invasive fungal infections with Candida species, Aspergillus species, and Cryptococcus neoformans. In contrast, infections with Blastomyces dermatitidis have rarely been diagnosed in transplant recipients. We describe a patient who received an orthotopic heart transplant and developed recurrent disseminated blastomycosis. Other reported cases of blastomycosis in transplant recipients are summarized. Clinical presentation, treatment options, and morbidity associated with infections with B. dermatitidis in transplant patients are reviewed.

Evaluation of risk factors for blastomycosis in dogs: 857 cases (1980-1990)

An epidemiologic study was conducted by use of the Veterinary Medical Data Base to investigate risk factors for blastomycosis in dogs. From January 1980 through June 1990, 971 cases of blastomycosis in dogs from 22 North American veterinary teaching hospitals were identified. Of these cases, 114 (11.7%) were excluded from the study because of incomplete information regarding age, body weight, sex, and neuter status. A control group of 417,079 dogs was selected that included all other dogs with medical conditions unrelated to blastomycosis for which records were submitted to the data base during the same period. The prevalence of blastomycosis in dogs was 205/100,000 admissions during the study period. When veterinary teaching hospitals were grouped on the basis of their general geographic location, dogs in the East South central, East North central, West South central, and South Atlantic regions had a significantly (P < 0.05) increased risk of acquiring blastomycosis, compared with that of dogs in the Mountain/Pacific region. When teaching hospitals from all geographic regions were considered, dogs had a significantly (P < 0.05) increased risk of acquiring blastomycosis in autumn, compared with that in spring. Sporting dogs and hounds, as defined by the American Kennel Club, were at increased risk for blastomycosis. At highest risk were Bluetick Coonhounds, Treeing-walker Coonhounds, Pointers, and Weimaraners, compared with mixed-breed dogs. Ages of dogs with blastomycosis tended to be normally distributed. Generally, the highest-risk group was composed of sexually intact male dogs, 2 to 4 years old, weighing 22.7 to 34.1 kg. This same pattern was observed for sporting dogs and hounds.(ABSTRACT TRUNCATED AT 250 WORDS)

Blastomycosis

Blastomycosis is a rare but important fungal infection that occurs primarily in the south central and midwestern United States. Epidemics of blastomycosis related to a point-source exposure include patients of all ages and both sexes; however, cases of endemic blastomycosis are usually in young to middle-aged adults and are reported more for men than for women. Pneumonia is the most common manifestation of blastomycosis, and the lungs are almost always the organ initially infected. Skin, bone, prostate, and central nervous system are the next most frequently infected organs in descending order. Amphotericin B is curative, but because of its toxic effects, oral agents have been investigated as therapy for blastomycosis. ketoconazole should replace amphotericin B as therapy for blastomycosis that is not life threatening. Itraconazole is an experimental agent that is perhaps even more effective than ketoconazole. The therapeutic usefulness of fluconazole for blastomycosis remains unproven. For patients with life-threatening or central nervous system blastomycosis, amphotericin B remains the treatment of choice.

Asymptomatic blastomycosis of the central nervous system with progression in patients given ketoconazole therapy: a report of two cases

Ketoconazole (KTZ) has largely replaced amphotericin B as first-line therapy for blastomycosis. However, KTZ penetrates poorly into the central nervous system (CNS), and therapeutic failure may be caused by initially unrecognized CNS infection. Two patients (22% [2/9] of all culture-proven cases of blastomycosis at Grady Memorial Hospital, Atlanta, over 15 years) developed CNS blastomycosis while receiving KTZ. Neither initially had CNS symptoms; both had cutaneous and pulmonary disease that responded to KTZ. If KTZ or other fungistatic imidazoles are to continue as primary therapy for blastomycosis, studies are needed to improve the ability to identify patients likely to experience treatment failure or develop CNS disease. Possibly all patients with disseminated blastomycosis, even those without CNS symptoms, should have lumbar puncture and computed tomography of the head before therapy. Critical evaluation of their immune function also may be required before making a therapeutic decision to use KTZ or amphotericin B.

Cutaneous blastomycosis as a complication of transthoracic needle aspiration

A patient with an ill defined density in the left upper lobe underwent transthoracic needle aspiration. A diagnosis of Blastomyces dermatitidis was made from the aspiration. The patient later returned with a cutaneous ulcer at the site of needle aspiration. B dermatitidis was subsequently recovered from the skin lesion.

Blastomycosis-like pyoderma--report of a case responsive to combination therapy utilizing minocycline and carbon dioxide laser debridement

Blastomycosis-like pyoderma is an uncommon reaction pattern to a superficial bacterial infection in persons with a variety of predisposing conditions such as chronic ethanol use and poor nutrition. We are reporting a case that initially responded poorly to previously described treatment regimens but responded well to combination treatment with carbon dioxide laser debridement and long-term minocycline.

Isolation of Blastomyces dermatitidis in soil associated with a large outbreak of blastomycosis in Wisconsin

In investigating six cases of blastomycosis in two school groups that had separately visited an environmental camp in northern Wisconsin in June 1984, we identified a large outbreak of the disease and isolated Blastomyces dermatitidis from soil at a beaver pond near the camp. Of 89 elementary-school children and 10 adults from the two groups, 48 (51 percent) of the 95 evaluated in September had blastomycosis. Of the cases, 26 (54 percent) were symptomatic (the median incubation period was 45 days; range, 21 to 106 days). No cases were identified in 10 groups that visited the camp two weeks before or after these two groups. A review of camp itineraries, a questionnaire survey, and environmental investigation showed that blastomycosis occurred in two of four groups that visited a beaver pond and in none of eight groups that did not. Walking on the beaver lodge (P = 0.008) and picking up items from its soil (P = 0.05) were associated with illness. Cultures of soil from the beaver lodge and decomposed wood near the beaver dam yielded B. dermatitidis. We conclude that B. dermatitidis in the soil can be a reservoir for human infection.

Failure of ketoconazole in an immunosuppressed patient with pulmonary blastomycosis

A renal transplant recipient presented with pulmonary blastomycosis. Because of recent data suggesting a role for ketoconazole in the treatment of blastomycosis and concern for preserving her functioning renal transplant, she was started on therapy with ketoconazole, 400 mg daily. After four months of continuous therapy, she developed skin and laryngeal involvement requiring emergency tracheostomy; subsequent therapy with amphotericin B resulted in resolution of her disease. This is an example of life-threatening progression of blastomycosis in an immunosuppressed patient during ketoconazole therapy.

Disseminated inoculation blastomycosis in a renal transplant recipient

We report a case of inoculation blastomycosis with dissemination to the lungs. The patient, a renal allograft recipient, was inoculated accidentally at the veterinarian's office where she worked. A nodular lesion appeared at the inoculation site, accompanied by lymphadenopathy and fever. Pulmonary infiltrates developed. Blastomyces dermatitidis was identified by both biopsy and culture from both inoculation site and lungs. Although not previously reported, inoculation blastomycosis can disseminate in an immunocompromised patient.

Miliary pulmonary blastomycosis

Five patients with proved blastomycosis had a diffuse miliary nodular pattern seen on chest radiographs. These cases are presented to emphasize that blastomycosis may be the cause of a miliary pattern in an endemic area. Documentation requires recovery of the organism from body fluids or tissue since skin and serologic testing are unreliable indicators of active disease. With prompt diagnosis and appropriate treatment, the patient may recover from this form of endogenous disseminated reinfection that otherwise may be fatal, particularly in the immunocompromised host.

Pulmonary blastomycosis: filamentous forms in an immunocompromised patient with fulminating respiratory failure

A 72-year-old woman with Sjögren's syndrome manifested acute fulminating respiratory failure and was treated with high-dose corticosteroids. Autopsy revealed overwhelming pulmonary infection by Blastomyces dermatitidis with no evidence of extrapulmonary dissemination. Hyphal forms, usually not observed in vivo, were noted in premortem sputum samples as well as in sections of lung obtained at autopsy. It is proposed that the immunocompromised state of the patient played a pathogenetic role in the fulminating clinical course as well as in the production of filamentous forms of B. dermatitidis.

Pathogen factors and host factors in murine pulmonary blastomycosis

Factors related to pathogenesis were studied in a murine model of pulmonary fungal infection with strains of Blastomyces dermatitidis. Strain 26199V was greater than or equal to 10(5)-fold more lethal in pulmonary challenge than strain GA-1. This relationship between the two strains also occurred after intraperitoneal challenge. Serial studies with lung cultures and histology of sacrificed animals after pulmonary challenge with similar doses, and challenge studies in mice of differing maturity, indicated GA-1 is impaired in initial replication in situ, although the two strains grow equally well in the presence of murine substrates in vitro. In vitro studies indicated the two strains were indistinguishable in most studies of biochemical and metabolic markers, and in studies with chemical and physical inhibitors. The exceptions were their morphologic appearance in the yeast phase, ability to hydrolyze esculin, and susceptibility to crystal violet dye and bile. The last finding and previous work suggested possible differences in lipid content; these were confirmed in studies which also included two other strains. Greater phospholipid and palmitic acid content were associated with greater virulence.

North American blastomycosis in an immunosuppressed patient

A 49-year-old man with sarcoidosis presented with a large nonhealing verrucous and eroded lesion (of two years' duration) over the left flank. Biopsy of the lesion revealed granulomatous infiltration, and special fungal stains showed the typical broad-necked budding structure of Bastomyces dermatitidis. The patient underwent en masse surgical removal of the lesion followed by systemic administration of amphotericin B. This report emphasizes the need for skin biopsy for nonhealing ulcers of unknown etiology, reviews the natural history of North American blastomycosis, and speculates on its relationship to immunosuppression.

Disseminated Trichosporon beigelii (cutaneum)

Two cases of invasive Trichosporon beigelii (syn. cutaneum) infection are reported and are compared with the eight other previous reports. All affected patients were either immunosuppressed or had recently undergone a surgical procedure. The diagnosis had been delayed and the prognosis was poor. Only two patients recovered after vigorous antimycotic therapy and concomitant remission of their leukemia. A biopsy of the skin lesion, as illustrated in one of our patients, may prove to be useful in the early diagnosis.