Case Presentation: A 55 year-old previously incarcerated male with a history of treated tuberculosis presented to the emergency department (ED) with right hand infection. On admission, he was hypoxic with notable skin lesions on bilateral hands and face. He denied any recent travel. He had a remote employment history of yardwork, but not within the past decade. Vitals on admission were remarkable for tachycardia, tachypnea, hypotension, and mild fever. He had a few episodes of hemoptysis in the ED and endorsed subjective fevers and chills. Upon examination, he had respiratory distress, annular skin lesions on his face and left hand, and a right forearm proximal subcutaneous abscess. Labs were remarkable for leukocytosis, anemia, thrombocytosis, and elevated LFTs. Due to concern for tuberculosis, patient was placed in isolation pending further workup. Chest x-ray and CT chest/abd/pelvis were obtained. An extensive infectious workup was initiated. Patient was initially started on vancomycin and ceftriaxone and underwent debridement of his right hand. Chest x-ray revealed bilateral interstitial opacities, and CT was notable for multifocal consolidations. AFB cultures and QuantiFERON TB were negative. Debridement tissue sample and punch biopsy of left lower lip both revealed broad-based budding organisms and urine was positive for histo/blasto antigen. Brain MRI was negative for CNS involvement. Patient was started on Amphotericin and Itraconazole and was weaned off supplemental oxygen on hospital day #3.
Discussion: Here we report a case of disseminated blastomycosis in an immunocompetent patient without a definitive exposure history. Tuberculosis was the leading diagnosis based on the patient’s presentation and history, however, this case highlights the importance of considering the geographic region for accurate diagnosis. Interestingly, the patient did not demonstrate pulmonary symptoms until a few weeks after the bone and cutaneous manifestations. Treatment for mild disease is itraconazole, while more severe disease is treated with amphotericin.
Conclusions: Disseminated blastomycosis is a rare fungal infection that is more often seen in those with a compromised immune system. While lung involvement is usually the primary manifestation, it is also known to affect the skin and bone. Given the associated morbidity and mortality, disseminated blastomycosis should be a leading differential diagnosis in endemic areas. These regions include states bordering the Mississippi and Ohio Rivers and the Great Lakes.