Case Presentation: A 68-year-old female with a history of Parkinson’s disease presented in the outpatient setting with a complaint of a spider bite on her right lower extremity. Over the course of a month this area of erythema progressed, and she developed generalized malaise, nonproductive cough, subjective fevers and chills, night sweats, dyspnea and worsening headaches. She had no known environmental exposures or travel history. She lives in southern West Virginia and has no known immunosuppression. Her exam was significant for a painful ulcer with a purulent base and erythematous undermined borders on the right medial lower leg above the medial malleolus, the rest of her exam was unremarkable.She was initially diagnosed by Dermatology with Pyoderma Gangrenosum and was treated with systemic steroids. Approximately three months later, still without any improvement, two punch biopsies were performed, and the cultures resulted with numerous spores with refractile walls and broad-based budding consistent with Blastomycosis. Following this, due to concern for systemic disease further imaging was obtained. A CT of the chest, abdomen and pelvis and MRI of the brain showed findings in the lungs, liver and uterus that were concerning for dissemination. Following her outpatient diagnosis, she was admitted for an induction 7-day course of IV Amphotericin B. Due to her complaints of acute on chronic dizziness and headaches a lumbar puncture was performed without any findings to suggest CNS involvement. Her course was complicated by hypotension, shortness of breath and chest discomfort which was attributed to the Amphotericin B as well an interaction with her Carbidopa/ Levodopa. Her symptoms significantly improved with premedication, intravenous fluids and adjustment of the infusion rate. After her course of Amphotericin B she was transitioned to PO Itraconazole with plans to remain on this for at least 12 months.
Discussion: Blastomycosis dermatitidis is a systemic pyogranulomatous infection that arises after inhalation of the fungus. The most common sites of involvement are the lungs, followed by the skin, bones, genitourinary and central nervous system. Ulcerative lesions that bleed easily and have well-demarcated, heaped-up borders are frequently misdiagnosed as Pyoderma Gangrenosum, which is why it is important to recognize a non-healing ulcer as an early presenting symptom to prevent a delay in diagnosis. In patients with moderate to severe pulmonary involvement or disseminated disease Amphotericin B is commonly used as treatment. The lipid formulation has been found to be less nephrotoxic and with fewer infusion toxicities, which is why it is more commonly used over Amphotericin B deoxycholate. As we saw in our patient, there are also many associated systemic side effects. These can include dyspnea, chest pain, fevers, chills, dizziness and headaches in addition to drug-drug interactions. In collaboration with pharmacy, infusion adjustments as well as symptom-targeted premedication can help minimize infusion-related reactions.
Conclusions: Disseminated blastomycosis can affect almost any part of the body and present in many ways emphasizing the importance of being able to recognize uncommon causes of a non-healing ulcer in an immunocompetent patient. The treatment regimen generally consists of an induction phase with Amphotericin B infusion. Therefore, being aware of the associated side effects of this medication and how to appropriately manage them is an important element of the treatment plan.