A 23–year–old African American Midwestern gentleman with history of subaortic stenosis repair had presented to the Emergency Department (ED) with complaints of pain and swelling in the left ankle, left chest wall and left hand, night sweats and weight loss. Examination was significant for low grade fever, tachycardia and tender swellings in the sites mentioned. Labs showed no leukocytosis but elevated ESR and CRP. CT chest showed pneumonia in the left lower lobe with diffuse reticulonodular opacities, along with a possible chest wall abscess. CT abdomen and pelvis showed hypodense lesions in the spleen. MRI of the left ankle and left hand suggested osteomyelitis. He was empirically treated with vancomycin and cefepime in the ED, which were stopped the next day as there was no evidence of a bacterial infection. Trans–esophageal echocardiography showed no evidence of vegetations. Left ankle synovial fluid aerobic and anaerobic cultures were negative. Peripheral blood cultures were negative for bacteria and fungi. HIV screen was negative. Fungal antibody survey was negative. PPD skin test was non–reactive. He remained hemodynamically stable except for intermittent fever spikes and was off any antimicrobials; he developed new growths on the right shoulder and right elbow. Bone biopsies were obtained from left tibia and fibula, and skin biopsies from the right shoulder and right elbow for histopathology and cultures. Left chest wall abscess was drained by CT guidance, but fluid cultures were sterile. Later, urine Histoplasma and Blastomyces antigen tests reported positive. Pathology from bone biopsy, left chest wall abscess core biopsy along with skin biopsy of the right shoulder and right elbow reported Blastomyces dermatiditis organisms. Fungal cultures from synovial fluid were also positive for Blastomyces. He was then treated with intravenous liposomal amphotericin B for 3 weeks after which oral itraconazole was started for a total duration of 6 months. When seen in follow–up at the completion of the intravenous antibiotic, examination revealed resolution of the swelling at the ankle, hand and the chest wall, and he felt better symptomatically.
Blastomycosis is primarily a pulmonary infection, but dissemination occurs frequently to cause cutaneous, osteoarticular and genitourinary manifestations, and rarely causing splenic abscesses. Widely disseminated disease is more common in immunocompromised patients. Diagnosis can be delayed because of failure to consider the diagnosis. Histopathological examination of tissue specimens with use of methenamine silver or periodic acid–Schiff (PAS) is the usual diagnostic method for extrapulmonary disease.
In an immunocompetent individual, the chances for a disseminated infection, mainly fungal are low, especially in situations of hemodynamic stability and low likelihood of a bacterial infection. The sites of involvement should help indicate the increased likelihood of possible fungal infections