Blastomycosis

History  43 male smoker 25 pack seen at OPD  Unresolving respiratory symptoms for 6/12  Chronic cough with green sputum  now repeated minimal hemoptysis  now repeated minimal hemoptysis  Fever with night sweating intermittent  Wt loss 45 lbs  SOBE mild effort

History  No orthopnea, PND or CP  No leg pain or swelling  NO CTD symptoms  No contact,travel  Works in courier service  No pets  PMH & PSH & FH :-ve

History  Trial of Abx 2 courses Amoxil 2 weeks & Gatifluxacine 3 months Amoxil 2 weeks & Gatifluxacine 3 months  no improvement  no improvement  Off work being symptomatic  Referred ? Malignancy

Examination  Afebrile RR 16 Sat 96% RA  BP 130/70 HR 80  No clubbing  Chest : minimal crackles Lt lower 1/3  CVS : N  ABD & LL N  No CTD signs

Investigations  CBC Coagulation N  BUN, Creat, lytes N  LFT N  UA N  CXR  Airspace disease lingula & LLL ?Lt hilar enlargement ?Lt hilar enlargement  CT Chest

Investigations  Bronchoscopy  N  BAL cytology  -ve for malignancy  Initial culture  strept & H.Inf  3 weeks after Bronch  new growth

Blastomycosis

Blastomycosis  Blastomyces dermatitidis is a dimorphic fungus  mycelial form at room temperature  mycelial form at room temperature & yeast form at body temperature. & yeast form at body temperature.  Etiology of spectrum of diseases that occur either in sporadic or epidemic cases.  2 serotypes : A antigen +ve or –ve {mainly in Africa}

Epidemiology  Estimating incidence has been difficult  lack of sensitive & specific diagnostic tests  lack of sensitive & specific diagnostic tests considerable number of cases are subclinical considerable number of cases are subclinical  Based on clinical reports of cases endemic areas are states bordering Mississippi & Ohio rivers states bordering Mississippi & Ohio rivers  Southeastern & South-central  Southeastern & South-central & states bordering the great lakes  Canadian provinces, Midwestern  Canadian provinces, Midwestern

Epidemiology  Environment is soil containing decayed vegetations or decomposed woods  Rain fall or proximity to water source maintaining humidity is a major factor  Those environmental factors are short lived

Presentations  Infection through inhalation of conidia from the ruptured mycelia.  Conidia then rapidly converts to yeast form which more resistant to phagocytosis.  Host defense is cellular  doesn't confer immunity or fasten recovery.  doesn't confer immunity or fasten recovery.

Presentations  General : fever, malaise,fatigue & Wt loss  Pulmonary : Acute resemble CAP Chronic might be mistaken for malignancy Reported cases  empyema & ARDS CXR  alveolar disease CXR  alveolar disease upper lobes predominance upper lobes predominance or Mass, miliary reticulonodular pattern or Mass, miliary reticulonodular pattern Cavitations & effusions are rare Cavitations & effusions are rare

Presentations  Cutaneous: 2 nd most common Isolated or concomitant with respiratory involvement Either verrucous or ulcerative lesions Aspirations or Bx will yield Dx  Osseous : both axial & peripheral bones radiological findings are non specific radiological findings are non specific Bx  granulomatous inflammation Bx  granulomatous inflammation

Presentations  CNS : Meningitis, abscess Ventricular fluid has a higher yield than LP Ventricular fluid has a higher yield than LP  GU : Prostatitis & epididmoorchitis  Rare : LN, Liver & spleen abscess ocular,adrenal, breast ocular,adrenal, breast Presenting with ITP, Immune hemolysis Presenting with ITP, Immune hemolysis Associated with TB, Histo & Coccidio Associated with TB, Histo & Coccidio

Presentations  Retrospective study In Manitoba Jan 1988  Dec 1999 Jan 1988  Dec 1999 Dx  clinically either pneumonia or skin lesions & isolation of fungus by culture or cytology & isolation of fungus by culture or cytology  143 patients 58.7% Manitoba resident & 41.3% Ontario resident & 41.3% Ontario resident  Mean Age 38+/- 20 M:F 65% Vs 35% CID May 2002 CID May 2002

Presentations  68% Manitoba residents have a +ve travel history of which 41% to Northwestern Ontario  Outdoor occupation 13.5% (occupation was available 138/143 patients ) (occupation was available 138/143 patients )  Annual incidence 0.62 per 100,000 Manitoba 7.1 per 100,000 Kenora ON 7.1 per 100,000 Kenora ON

Presentations  Manitoba incidence is half the incidence in endemic area Wisconsin & Mississippi  Kenora incidence 4 times other Manitoba or ON divisions.  Mortality rate 6.3% mainly respiratory failure Mortality was higher in patients with shorter symptoms before diagnosis Mortality was higher in patients with shorter symptoms before diagnosis

Diagnosis  Blastomyces is not a normal flora  either seeing or culturing it is reliable for Dx  either seeing or culturing it is reliable for Dx  Serology is not helpful because of cross reactivity with other fungi  epidemiological assessment  Skin testing  high false –ve results

Diagnosis  Retrospective study 119 patients  47% pulmonary involvement  Inclusion 1) Isolation from respiratory samples 1) Isolation from respiratory samples 2) Isolation from non respiratory sample 2) Isolation from non respiratory sample + clinical & radiological picture of pneumonia + clinical & radiological picture of pneumonia 3) Clinical & Radiological suspicion 3) Clinical & Radiological suspicion & +ve serology & +ve serology Chest Mar 2002 Chest Mar 2002

Diagnosis  High diagnostic yields from culture specimen &culturing different sources will increase yield  Increase number of specimens increase yield  Average time to confirm Dxby Culture  5 weeks  5 weeks

Diagnosis  KOH may provide faster & comparable yield to cultures  Serology yield 16-40%  Wet smear & cytology might be helpful in endemic areas endemic areas when starting treatment is urgent when starting treatment is urgent to avoid more invasive investigations to avoid more invasive investigations

Treatment  Spontaneous resolution is very uncommon  Untreated cases might have mortality 60%  No randomized trial comparing antifungal Rx  Rx selection depends on immune status & severity of infection & severity of infection Infectious dis clin 2003 Infectious dis clin 2003

Treatment  Immunocompromized with CNS,Respiratory failure or multioragn failure  Ampho B  Itraconazole is the drug of choice 200 mg. 6 months cure rate > 90% 6 months cure rate > 90%  Ketoconazole variable cure rates with higher CNS relapse with higher CNS relapse