EPI Update, August 6, 2010

Weekly newsletter for Center For Acute Disease Epidemiology of Iowa Department of Public Health

Unusual osseous presentation of blastomycosis in an immigrant child: a challenge for European pediatricians.

Blastomycosis, caused by the thermally dimorphic fungus Blastomyces dermatitidis is a systemic pyogranulomatous infection, endemic in United States and Canada, with few reported cases in Africa and Asia. It is uncommon among children and adolescents, ranging from 3% to 10%. Clinical features vary from asymptomatic spontaneously healing pneumonia, through acute or chronic pneumonia, to a malignant appearing lung mass. Blastomycosis can originate a "metastatic disease" in the skin, bones, genitourinary tract and central nervous system. Bone is the third most common site of blastomycotic lesions, after lung and skin. Bones may be involved in 14-60% of cases of blastomycosis. Direct visualization of single broadbased budding yeast with specific stains in sputum or tissue samples at microscopy is the primary method for diagnosis, while culture is timeconsuming and other methods are unreliable. CASE PRESENTATION: We report a case of severe osteoarticular Blastomycosis occurring in a 3-years-old presented to our Emergency Department with pain and swelling of the left knee, successfully treated with surgical curettage and antifungal therapy. To our knowledge this is the first case reported in Europe. CONCLUSIONS: Blastomycosis represents a challenge for European physicians, and it should be included in the differential diagnosis of unexplained infections in patients coming from endemic areas

Blastomyces Antigen Detection for Monitoring Progression of Blastomycosis in a Pregnant Adolescent

Although disseminated blastomycosis is a rare complication in pregnancy, delay in diagnosis and treatment can be fatal. We investigate the use of the Blastomyces urine antigen in diagnosis following disease progression in the intrapartum, postpartum, and neonatal periods. We describe a case of disseminated blastomycosis in a pregnant adolescent and review the pertinent literature regarding treatment and monitoring blastomycosis in pregnancy and the neonatal periods. This is the first reported case in which the Blastomyces urine antigen is utilized as a method of following disease activity during pregnancy confirming absence of clinically evident disease in a neonate. Urine antigen detection for blastomycosis can be useful for following progression of disease in patients with disseminated blastomycosis in both the intrapartum and postpartum periods

An adolescent with both Wegener's Granulomatosis and chronic blastomycosis

We report a case of Wegener's Granulomatosis (WG) associated with blastomycosis. This appears to be the first case report of WG co-existing with a tissue proven blastomycosis infection. The temporal correlation of the two conditions suggests that blastomycosis infection (and therefore possibly other fungal infections), may trigger the systemic granulomatous vasculitis in a predisposed individual; a provocative supposition warranting further study

Pulmonary blastomycosis on autopsy: a rare case report

A case of pulmonary blastomycosis on autopsy in a middle aged male from rural background is presented herewith. Blastomycosis is a pyogranulomatous disease caused by the dimorphic fungus blastomyces dermatitidis. Blastomycosis is endemic in regions of North America that border the Great Lakes. It is one of the great mimickers in medicine. Pulmonary blastomycosis has a broad range of clinical presentations, varying from completely asymptomatic pulmonary infiltrates to diffuse and massive parenchymal involvement that can lead to Acute Respiratory Distress Syndrome (ARDS). Human infection occurs when soil containing microfoci of mycelia is distributed and airborne conidia are inhaled. If natural defences in the alveoli fail to contain the infection, lymphohematogenous dissemination ensues. Diagnosis is based on culture and direct visualization of round, multinucleated yeast forms that produce daughter cells from a single broad- based bud. Most of the cases of blastomycosis reported in India are imported from the endemic areas of the World except a few authochthonous cases in North India

Pre-Columbian Tuberculosis: An Epidemiological Approach

In this study we have combined both biological and cultural data in the investigation of resorptive pathology in Woodland and Mississippian skeletal series from west-central Illinois. Information concerning the types of lesions and their distribution confirms the presence of a previously unknown disease in Mississippian populations. Adults and adolescents from Yokem and Schild Mississippian components clearly display cystic vertebral pathology, which in association with other peripheral osseous lesions distinguishes them from earlier groups. This idea is supported indirectly by evidence from both infants and children of the Schild sample

North American Blastomycosis in Rhodesia

A CAJM article on the prevalence of American blastomycosis in Zimbabwe (formerly Rhodesia.)The clinical and pathological features of North American Blastomycosis in the United States of America have been well documented by Abernathy (1959) and by Witorsch & Utz (1968) who showed that blastomycosis is a chronic mycosis generally believed to begin in the lungs and which then spreads to other organs giving rise to secondary lesions, especially in the skin and bones

Non-resolving Community Acquired Pneumonia (CAP) due to Blastomyces dermatitidis (Pulmonary Blastomycosis): Case Report and Review of Literature

In this case report, we describe a case of progressive acute pulmonary blastomycosis in a healthy adult living in Kentucky, initially presenting with flu like illness with a left sided consolidation, who did not respond to antibiotic therapy. Patient’s clinical condition deteriorated with development of necrotizing bronchopneumonia, mediastinal lymphadenopathy, tree-in-bud reticulonodularity and pleural effusion. A diagnosis of progressive pulmonary blastomycosis was established by radiological findings as well as transbronchial needle aspiration cytology and bronchoalveolar lavage culture demonstrating Blastomyces dermatitidis. Patient showed significant clinical improvement with resolution of pulmonary lesions on antifungal treatment. Since symptoms of blastomycosis are often similar to the symptoms of flu or other lung infections, our case highlights the importance of maintaining a high index of suspicion and appropriate microbiologic and histologic evaluation especially in patients who live in or have traveled to areas endemic for blastomycosis and are not responding to antibiotic therapy. Early diagnosis coupled with prompt initiation of antifungal treatment may lead to favorable outcomes