Case Presentation: The patient is a 53 year old female who presented with a black, patchy lesion under her eye that had been present for about 3 months. She said that it first began as a cyst that was manually drained and later scabbed over with occasional pain. As the pain persisted, she presented to an outside hospital and was given a dose of IV Clindamycin and later transferred to our hospital for further evaluation. Here, she received Unasyn and ophthalmology, ENT, and dermatology were consulted. Biopsy of the lesion was obtained and showed broad based buds, consistent with blastomycosis. Infectious disease recommended starting IV Amphotericin, and surgery on her maxillary sinus for concern of spread of the infection. However, she needed to go home to care for her daughter and agreed to return in a couple of days. She was sent home on Itraconazole and later returned for the surgery. On her arrival back, vitals were stable, and exam again showed this same lesion under her eye as well multiple pruritic lesions on her legs that had started at the same time, consistent with lesions typically seen in cutaneous blastomycosis. The rest of her exam was benign, and initial blood work was negative. MRI showed no spread of the infection to the CNS. Surgery of her sinus revealed osteomyelitis and a subperiosteal abscess. With concern for disseminated infection, IV Amphotericin was started. She was discharged with a plan for daily IV Amphotericin for 1 week, as well as oral Itraconazole for 12 months.
Discussion: Here we report a case of cutaneous blastomycosis complicated by maxillary osteomyelitis and a periosteal abscess in a patient without a clear exposure history. Most cases of blastomycosis have been reported in North America with endemic areas around the Ohio and Mississippi River valleys and the Great Lakes area. A patient’s pulmonary presentation can range from acute pneumonia with productive cough, fever, and dyspnea to acute respiratory distress syndrome due to diffuse pneumonitis. Skin lesions are typically verrucous, ulcerative, or nodular. Osteomyelitis may present with soft tissue swelling and a chronic draining sinus tract. Usually this infection can be treated with Itraconazole while more serious and disseminated cases require treatment with IV Amphotericin. With the proper treatment, most patients are able to make a full recovery. However, mortality rates range from 4-22%. In this case, we highlight the importance of considering blastomycosis, particularly in the setting of pulmonary, skin, and bone infections.
Conclusions: Blastomycosis is a rare fungal infection acquired through inhalation that typically manifests as a pulmonary disease, but can affect any organ including the skin and bones. Early recognition of this infection is essential for proper treatment and management.