51 y.o. Man with Bilateral Osteomyelitis of the Hands David Feldstein, MD PCC 5/10/06

Patient 51 y.o. man with hx of pulmonary sarcoidosis 51 y.o. man with hx of pulmonary sarcoidosis –Osteomyelitis of bilateral 5 th fingers 8 weeks (PTA) 8 weeks (PTA) –Pain, erythema, swelling right 5 th PIP joint –No trauma, injury, fevers chills –Urgent care – clinical dx fracture and splinted

Patient 7 weeks (PTA) 7 weeks (PTA) –Return UC increased swelling and pain –Xray with bony destruction head of 5 th proximal phalynx –Ceftri x 1 and started on cephalexin 4 weeks (PTA) 4 weeks (PTA) –Admitted to outside hospital –Progression of sx right 5 th finger –Left 5 th finger now with swelling and erythema

Patient Outside Hospital Outside Hospital –Xray »Almost complete destruction right 5 th middle phalynx »Lucency left 5 th proximal phalynx –Bone scan »Increased signal bilateral 5 th fingers and right wrist

Patient Outside Hospital Management Outside Hospital Management –Incision and drainage right 5 th finger –Pin placed for stabilization –Gram stain and cx of fluid negative –Vancomycin /Rifampin and discharged No clinical improvement and worsening xrays 3 weeks later No clinical improvement and worsening xrays 3 weeks later Sent to UW (FINALLY!!) Sent to UW (FINALLY!!)

Why? Why did he fail treatment? Why did he fail treatment?

At UW No constitutional sx or other skin findings No constitutional sx or other skin findings PMH – Sarcoidosis PMH – Sarcoidosis SH – Machinist, lives on a farm SH – Machinist, lives on a farm PE PE –VSS, NAD –Lungs clear –Skin – see photos

Objectives Recognize improper treatment of osteomyelitis Recognize improper treatment of osteomyelitis Describe symptoms of blastomycosis infection Describe symptoms of blastomycosis infection Describe treatment of blastomycosis Describe treatment of blastomycosis

Blastomyces Dermatitidis Dimorphic fungus Dimorphic fungus Mycelial phase in nature Mycelial phase in nature Converts to yeast at body temperature Converts to yeast at body temperature Warm moist soil in wooded areas rich in organic debris Warm moist soil in wooded areas rich in organic debris Endemic – See figure Endemic – See figure

Rippon JW. Medical Mycology: The Pathogenic Fungi and Pathogenic Actinomycetes. 3rd ed. Philadelphia: WB Saunders; 1988:474. Incidence of Blastomycosis in North America

Clinical Manifestations Very variable Very variable Infection caused by inhalation in almost all cases Infection caused by inhalation in almost all cases Most cases include symptomatic pulmonary infection Most cases include symptomatic pulmonary infection

Wisconsin 2 retrospective studies 2 retrospective studies –Centers for Disease Control and Prevention (CDC). Blastomycosis-- Wisconsin, (1996) –Baumgardner DJ. Halsmer SE. Egan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. (2004)

CDC All reported cases in WI All reported cases in WI –670 cases –29 fatal Primary pulmonary disease without extrapulmonary manifestations Primary pulmonary disease without extrapulmonary manifestations –76% Extrapulmonary disease only Extrapulmonary disease only –18% Pulmonary and Extrapulmonary Pulmonary and Extrapulmonary –6%

Baumgardner Retrospective investigation of 170 reported cases in Vilas County Retrospective investigation of 170 reported cases in Vilas County – –91% pulmonary symptoms Pulmonary cases contacted and interviewed (118 of 154) Pulmonary cases contacted and interviewed (118 of 154)

Patients with Pulmonary Blasto Baumgardner, etal. Cough90% Fever75% Night Sweats 68% Weight Loss 68% Chest Pain 63% Dyspnea54% Myalgias50% Hemoptysis18%

Common Extrapulmonary Sx Skin Skin –Verrucous or ulcerative Bone Bone –Any bone –Xrays not specific GU GU –Prostatitis and epididymoorchitis CNS CNS –Epidural or cranial abscesses

Diagnosis Diagnosis Diagnosis –Histology –Culture »Easy to culture Serology Serology –Not sensitive or specific –95% cross reactivity with Histo –Also cross-reactive with paracoccidiodomycosis

Treatment No good RCTs No good RCTs Guidelines based on small open label studies, case series and expert opinion Guidelines based on small open label studies, case series and expert opinion Ampho for life threatening Ampho for life threatening Itraconazole for mild to moderate Itraconazole for mild to moderate At least 6 months At least 6 months

IDSA Guidelines Pulmonary –Life threatening – Amphotericin B –Mild/Mod – Itraconazole Disseminated CNS – Ampho B CNS – Ampho B Non-CNS Non-CNS –Life threatening – Ampho B –Mild/Mod - Itraconazole

Clinical Follow-up

Conclusions Treatment of osteomyelitis Treatment of osteomyelitis –Bone Culture –Reassess when not responding Manifestations of Blasto Manifestations of Blasto –Pulmonary most common –Can affect almost any organ Treatment Treatment –Ampho or Itraconazole –No good trials of efficacy

References Centers for Disease Control and Prevention (CDC). Blastomycosis--Wisconsin, MMWR - Morbidity & Mortality Weekly Report. 45(28):601-3, 1996 Jul 19. Centers for Disease Control and Prevention (CDC). Blastomycosis--Wisconsin, MMWR - Morbidity & Mortality Weekly Report. 45(28):601-3, 1996 Jul 19. Baumgardner DJ. Halsmer SE. Egan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. Wilderness & Environmental Medicine. 15(4):250-6, Baumgardner DJ. Halsmer SE. Egan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. Wilderness & Environmental Medicine. 15(4):250-6, Chapman SW. Bradsher RW Jr. Campbell GD Jr. Pappas PG. Kauffman CA. Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America. Clinical Infectious Diseases. 30(4):679-83, 2000 Apr. Chapman SW. Bradsher RW Jr. Campbell GD Jr. Pappas PG. Kauffman CA. Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America. Clinical Infectious Diseases. 30(4):679-83, 2000 Apr.