Blastomycosis: Difference between revisions
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==Background== | ==Background== | ||
* [[Fungus]]: Blastomyces dermatitidis | *[[Fungus]]: Blastomyces dermatitidis | ||
* Lives in moist soil, wooded areas | *Lives in moist soil, wooded areas | ||
** Spores are airborne | **Spores are airborne | ||
* North, Central and South America | *North, Central and South America | ||
** Southeast and Midwest US (Mississippi and Ohio River valleys) | **Southeast and Midwest US (Mississippi and Ohio River valleys) | ||
*Causes a systemic pyogranulomatous infection | *Causes a systemic pyogranulomatous infection | ||
* '''Reportable disease''' | *'''Reportable disease''' | ||
==Clinical Features== | ==Clinical Features== | ||
*Up to 50% of cases will be asymptomatic | *Up to 50% of cases will be asymptomatic | ||
* Incubation period: 3-6 weeks | *Incubation period: 3-6 weeks | ||
* Flu like symptoms: [[Fever]], chills, cough, muscle aches, joint pain, [[chest pain]] | *Flu like symptoms: [[Fever]], chills, cough, muscle aches, joint pain, [[chest pain]] | ||
* Other systemic symptoms: Weight loss, night sweats, chills | *Other systemic symptoms: Weight loss, night sweats, chills | ||
* Pulmonary: most common | *Pulmonary: most common | ||
** Acute or chronic pneumonia | **Acute or chronic pneumonia | ||
** Diffuse pneumonitis, [[ARDS]] | **Diffuse pneumonitis, [[ARDS]] | ||
* Skin: | *Skin: | ||
** Verrucous lesion with irregular borders | **Verrucous lesion with irregular borders | ||
** Microabscess (cold), subcutaneous nodules | **Microabscess (cold), subcutaneous nodules like erythema nodosum | ||
** Ulcers that bleed easily and well-demarcated | **Ulcers that bleed easily and well-demarcated | ||
* Bone: Osteomyelitis, chronic draining sinus, paravertebral abscess | *Bone: Osteomyelitis, chronic draining sinus, paravertebral abscess | ||
* Genitourinary: [[Prostatitis]], [[ | *Genitourinary: [[Prostatitis]], [[Epididymorchitis]] | ||
* CNS: [[Meningitis]], epidural | *CNS: [[Meningitis]], [[epidural abscess]] [[Brain abscess]] in immunocompromised | ||
* Can involve breast, adrenal, thyroid, eye, lymph node, liver, spleen | *Can involve breast, adrenal, thyroid, eye, lymph node, liver, spleen | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* [[Pneumonia]] | *[[Pneumonia]] | ||
* Malignancy | *Malignancy | ||
* [[Tuberculosis]] | *[[Tuberculosis]] | ||
* [[Histoplasmosis]] | *[[Histoplasmosis]] | ||
* [[Pyoderma gangrenosum]] | *[[Pyoderma gangrenosum]] | ||
* Keratoacanthoma | *Keratoacanthoma | ||
== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
* Fungal culture (Blood, sputum, bone marrow, liver or skin) : Broad based buds | *Fungal culture (Blood, sputum, bone marrow, liver or skin) : Broad based buds | ||
* Antigen test (Serum or urine) | *Antigen test (Serum or urine) | ||
* Histopathology | *Histopathology | ||
* Serologic testing | *Serologic testing | ||
* HIV testing | *HIV testing | ||
* CXR: Alveolar infiltrates +/- cavitation, mass lesions, miliary or reticulo- or fibronodular pattern, pleural effusions, upper lobe infiltrate, perihilar lymph nodes | *[[CXR]]: Alveolar infiltrates +/- cavitation, mass lesions, miliary or reticulo- or fibronodular pattern, pleural effusions, upper lobe infiltrate, perihilar lymph nodes | ||
* Chest CT: Nodules, consolidation +/- cavitation, tree-in-bud opacities, pleural effusion, lack hilar adenopathy | *Chest CT: Nodules, consolidation +/- cavitation, tree-in-bud opacities, pleural effusion, lack hilar adenopathy | ||
* Xray of bone: Well-circumscribed osteolytic lesion | *Xray of bone: Well-circumscribed osteolytic lesion | ||
** Xray vertebrae: Lytic lesion in anterior vertebral body and destruction of disc space | **Xray vertebrae: Lytic lesion in anterior vertebral body and destruction of disc space | ||
* Bronchoscopy | *Bronchoscopy | ||
==Management== | ==Management== | ||
* ID consult | *ID consult | ||
* Mild or moderate infections: [[Itraconazole]] (200mg TID x 3 days then once or twice daily x 6-12 months) | *Mild or moderate infections: [[Itraconazole]] (200mg TID x 3 days then once or twice daily x 6-12 months) | ||
** Alternative: [[Fluconazole]] or [[ | **Alternative: [[Fluconazole]] or [[ketoconazole]] (400-800mg/day) | ||
**Azoles embryotoxic and teratogenic, avoid in pregnancy | **Azoles embryotoxic and teratogenic, avoid in pregnancy | ||
* Severe infection: [[Amphotericin B]] (Lipid 3-5mg/kg IV daily or deoxycholate 0.7-1mg/kg IV daily) | *Severe infection: [[Amphotericin B]] (Lipid 3-5mg/kg IV daily or deoxycholate 0.7-1mg/kg IV daily) | ||
** All immunocompromised patient should receive [[amphotericin B]] | **All immunocompromised patient should receive [[amphotericin B]] | ||
** Lipid for all patients, except children | **Lipid for all patients, except children | ||
** If CNS involvement, lipid for all patients | **If CNS involvement, lipid for all patients | ||
==Disposition== | ==Disposition== | ||
* Subclinical disease: Observation and no treatment | *Subclinical disease: Observation and no treatment | ||
* Patients with immunosuppression or progressive pulmonary or extrapulmonary symptoms need treatment and often admission | *Patients with immunosuppression or progressive pulmonary or extrapulmonary symptoms need treatment and often admission | ||
* Some may need ICU | *Some may need ICU | ||
==See Also== | ==See Also== | ||
| Line 65: | Line 65: | ||
==External Links== | ==External Links== | ||
* http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Blastomycosis.pdf | *http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Blastomycosis.pdf | ||
==References== | ==References== | ||
Latest revision as of 22:36, 26 December 2016
Background
- Fungus: Blastomyces dermatitidis
- Lives in moist soil, wooded areas
- Spores are airborne
- North, Central and South America
- Southeast and Midwest US (Mississippi and Ohio River valleys)
- Causes a systemic pyogranulomatous infection
- Reportable disease
Clinical Features
- Up to 50% of cases will be asymptomatic
- Incubation period: 3-6 weeks
- Flu like symptoms: Fever, chills, cough, muscle aches, joint pain, chest pain
- Other systemic symptoms: Weight loss, night sweats, chills
- Pulmonary: most common
- Acute or chronic pneumonia
- Diffuse pneumonitis, ARDS
- Skin:
- Verrucous lesion with irregular borders
- Microabscess (cold), subcutaneous nodules like erythema nodosum
- Ulcers that bleed easily and well-demarcated
- Bone: Osteomyelitis, chronic draining sinus, paravertebral abscess
- Genitourinary: Prostatitis, Epididymorchitis
- CNS: Meningitis, epidural abscess Brain abscess in immunocompromised
- Can involve breast, adrenal, thyroid, eye, lymph node, liver, spleen
Differential Diagnosis
- Pneumonia
- Malignancy
- Tuberculosis
- Histoplasmosis
- Pyoderma gangrenosum
- Keratoacanthoma
Evaluation
Workup
- Fungal culture (Blood, sputum, bone marrow, liver or skin) : Broad based buds
- Antigen test (Serum or urine)
- Histopathology
- Serologic testing
- HIV testing
- CXR: Alveolar infiltrates +/- cavitation, mass lesions, miliary or reticulo- or fibronodular pattern, pleural effusions, upper lobe infiltrate, perihilar lymph nodes
- Chest CT: Nodules, consolidation +/- cavitation, tree-in-bud opacities, pleural effusion, lack hilar adenopathy
- Xray of bone: Well-circumscribed osteolytic lesion
- Xray vertebrae: Lytic lesion in anterior vertebral body and destruction of disc space
- Bronchoscopy
Management
- ID consult
- Mild or moderate infections: Itraconazole (200mg TID x 3 days then once or twice daily x 6-12 months)
- Alternative: Fluconazole or ketoconazole (400-800mg/day)
- Azoles embryotoxic and teratogenic, avoid in pregnancy
- Severe infection: Amphotericin B (Lipid 3-5mg/kg IV daily or deoxycholate 0.7-1mg/kg IV daily)
- All immunocompromised patient should receive amphotericin B
- Lipid for all patients, except children
- If CNS involvement, lipid for all patients
Disposition
- Subclinical disease: Observation and no treatment
- Patients with immunosuppression or progressive pulmonary or extrapulmonary symptoms need treatment and often admission
- Some may need ICU