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{{Blastomycosis}} | {{Blastomycosis}} | ||
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==Overview== | ==Overview== | ||
Blastomycosis is a fungal infection caused by the organism ''[[Blastomyces dermatitidis]]''. It is [[endemic (epidemiology)| | [[Blastomycosis]] is a [[fungal]] [[infection]] caused by the [[organism]] ''[[Blastomyces dermatitidis]]''. It is [[endemic (epidemiology)|endemic]] in portions of the Mississippi river and Ohio river basins and around the Great Lakes in North America, and causes clinical symptoms such as [[fever]], [[Cough|productive cough]] and [[myalgia]]. The symptoms, develop between 3 to 15 weeks after exposure. Majority of the cases are self-limiting with out any progression. [[Antifungals]] are used to treat if symptoms persist for more than 4 weeks. Prognosis is good depending on the [[immune]] status of the individual.<ref name="www.cdc.gov">{{Cite web | last = | first = | title = CDC - Symptoms of Blastomycosis | url = http://www.cdc.gov/fungal/blastomycosis/symptoms.html | publisher = | date = | accessdate = 22 November 2013 }}</ref><ref name=Sherris>{{cite book | author = Ryan KJ; Ray CG (editors) | title = Sherris Medical Microbiology | edition = 4th ed. | pages = pp.676–8 |publisher = McGraw Hill | year = 2004 | id = ISBN 0838585299 }}</ref> | ||
<ref name=Sherris>{{cite book | author = Ryan KJ; Ray CG (editors) | title = Sherris Medical Microbiology | edition = 4th ed. | pages = pp.676–8 |publisher = McGraw Hill | year = 2004 | id = ISBN 0838585299 }}</ref> | |||
==Historical Perspective== | ==Historical Perspective== | ||
Blastomycosis was first described by Thomas Casper Gilchrist | [[Blastomycosis]] was first described in detail by Thomas Casper Gilchrist in 1894. | ||
==Pathophysiology== | ==Pathophysiology== | ||
Infection occurs by inhalation of the | [[Infection]] occurs by [[inhalation]] of the [[conidia]] from its natural soil habitat. It has an average incubation period of 3 weeks to 3 months after exposure. Once inhaled, they multiply in [[lungs]] and initiate neutrophilic response with subsequent [[Cell-mediated immunity|cell-mediated immune response]] leading to [[Suppurative|suppurative]] [[tissue]] destruction in [[lungs]], and may disseminate through [[blood]] and [[lymphatics]] to other [[organs]] including [[skin]], [[bone]], [[Genitourinary tract|genitourinary trac]]<nowiki/>t, and [[brain]]. The characteristic [[histopathological]] findings on [[sputum]] microscopy is the multi nucleated [[yeast]] form (budding).<ref name="pmid20375357">{{cite journal |vauthors=Saccente M, Woods GL |title=Clinical and laboratory update on blastomycosis |journal=Clin. Microbiol. Rev. |volume=23 |issue=2 |pages=367–81 |year=2010 |pmid=20375357 |pmc=2863359 |doi=10.1128/CMR.00056-09 |url=}}</ref><ref name="pmid23917880">{{cite journal |vauthors=Smith JA, Riddell J, Kauffman CA |title=Cutaneous manifestations of endemic mycoses |journal=Curr Infect Dis Rep |volume=15 |issue=5 |pages=440–9 |year=2013 |pmid=23917880 |doi=10.1007/s11908-013-0352-2 |url=}}</ref><ref name="pmid18070904">{{cite journal |vauthors=Koneti A, Linke MJ, Brummer E, Stevens DA |title=Evasion of innate immune responses: evidence for mannose binding lectin inhibition of tumor necrosis factor alpha production by macrophages in response to Blastomyces dermatitidis |journal=Infect. Immun. |volume=76 |issue=3 |pages=994–1002 |year=2008 |pmid=18070904 |pmc=2258846 |doi=10.1128/IAI.01185-07 |url=}}</ref> | ||
<ref name="pmid23917880">{{cite journal |vauthors=Smith JA, Riddell J, Kauffman CA |title=Cutaneous manifestations of endemic mycoses |journal=Curr Infect Dis Rep |volume=15 |issue=5 |pages=440–9 |year=2013 |pmid=23917880 |doi=10.1007/s11908-013-0352-2 |url=}}</ref> | |||
<ref name="pmid18070904">{{cite journal |vauthors=Koneti A, Linke MJ, Brummer E, Stevens DA |title=Evasion of innate immune responses: evidence for mannose binding lectin inhibition of tumor necrosis factor alpha production by macrophages in response to Blastomyces dermatitidis |journal=Infect. Immun. |volume=76 |issue=3 |pages=994–1002 |year=2008 |pmid=18070904 |pmc=2258846 |doi=10.1128/IAI.01185-07 |url=}}</ref> | |||
==Causes== | ==Causes== | ||
Blastomycosis is a fungal infection caused by [[Blastomyces dermatitidis|Blastomyces dermatitidis.]]<ref name=disalvo1992>{{cite book|last=DiSalvo|first=A.F.|title=Ecology of Blastomyces dermatitidis|year=1992|publisher=Plenum|pages=43–73|authorlink=Blastomycosis|editor=Al-Doory, Y., DiSalvo, A.F.}}</ref> | Blastomycosis is a [[fungal]] infection caused by [[Blastomyces dermatitidis|Blastomyces dermatitidis.]]<ref name=disalvo1992>{{cite book|last=DiSalvo|first=A.F.|title=Ecology of Blastomyces dermatitidis|year=1992|publisher=Plenum|pages=43–73|authorlink=Blastomycosis|editor=Al-Doory, Y., DiSalvo, A.F.}}</ref> | ||
==Differentiating Blastomycosis from other Diseases== | ==Differentiating Blastomycosis from other Diseases== | ||
Blastomycosis presents as a mild flu-like illness and needs to be differentiated from other fungal disorders | Blastomycosis presents as a mild flu-like illness and needs to be differentiated from other fungal disorders like [[coccidioidomycosis]], [[Histoplasmosis|histoplasmosis,]] [[aspergillosis]], [[Pneumocystis jirovecii pneumonia|pneumocystis pneumonia]][[Sporotrichosis|sandporotrichosis]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Blastomycosis is [[Endemic (epidemiology)|endemic]] in the Mississippi river and Ohio river basins and around the Great Lakes in United States.The annual [[incidence]] is less than 1 case per 100,000 people in Mississippi, Louisiana, Kentucky, and Arkansas. | Blastomycosis is [[Endemic (epidemiology)|endemic]] in the Mississippi river and Ohio river basins and around the Great Lakes in United States.The annual [[incidence]] is less than 1 case per 100,000 people in Mississippi, Louisiana, Kentucky, and Arkansas.<ref name="pmid1420675">{{cite journal |vauthors=Baumgardner DJ, Buggy BP, Mattson BJ, Burdick JS, Ludwig D |title=Epidemiology of blastomycosis in a region of high endemicity in north central Wisconsin |journal=Clin. Infect. Dis. |volume=15 |issue=4 |pages=629–35 |year=1992 |pmid=1420675 |doi= |url=}}</ref><ref name="pmid25339251">{{cite journal |vauthors=Khuu D, Shafir S, Bristow B, Sorvillo F |title=Blastomycosis mortality rates, United States, 1990-2010 |journal=Emerging Infect. Dis. |volume=20 |issue=11 |pages=1789–94 |year=2014 |pmid=25339251 |pmc=4214285 |doi=10.3201/eid2011.131175 |url=}}</ref> | ||
<ref name="pmid1420675">{{cite journal |vauthors=Baumgardner DJ, Buggy BP, Mattson BJ, Burdick JS, Ludwig D |title=Epidemiology of blastomycosis in a region of high endemicity in north central Wisconsin |journal=Clin. Infect. Dis. |volume=15 |issue=4 |pages=629–35 |year=1992 |pmid=1420675 |doi= |url=}}</ref> | |||
<ref name="pmid25339251">{{cite journal |vauthors=Khuu D, Shafir S, Bristow B, Sorvillo F |title=Blastomycosis mortality rates, United States, 1990-2010 |journal=Emerging Infect. Dis. |volume=20 |issue=11 |pages=1789–94 |year=2014 |pmid=25339251 |pmc=4214285 |doi=10.3201/eid2011.131175 |url=}}</ref> | |||
==Risk Factors== | ==Risk Factors== | ||
The risk factors are not well established for the acquisition of blastomycosis in endemic areas. However, studies point out the role of moist soil rich in organic debris as a source of transmission | The [[risk factors]] are not well established for the acquisition of blastomycosis even in endemic areas. However, studies point out the role of moist soil rich in organic debris as a source of transmission. | ||
==Screening== | ==Screening== | ||
According to the centers for disease control and prevention screening for blastomycosis is not recommended. | According to the centers for disease control and prevention screening for blastomycosis is not recommended. | ||
==Natural History,Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
Blastomycosis is a granulomatous disease entity, that can produce a wide | Blastomycosis is a [[granulomatous]] [[disease]] entity, that can produce a wide range of signs and symptoms, but in most cases, it is a mild illness. The symptoms include [[fever]], [[productive cough]], [[hemoptysis]] and [[weight loss]]. If left untreated, a significant proportion of these cases may further disseminate to other body parts, most commonly to skin, followed by [[bone]] and [[joint]], [[genitourinary system]] and other sites in the body ([[Nervous system]][[lymphatics|landymphatics]]). The route of spread is most commonly either hematogenous or [[lymphatic]]. Prognosis of the individual depends on the [[immune]] status of the individual and treatment, usually good in [[immunocompetent]] patients with treatment, on contrast prognosis is poor in patients even with treatment in [[Immunocompromised|immuno-compromised]] individuals. Complications that may develop with blastomycosis include [[cutaneous]] involvement can cause large sores with [[pus]] ([[Abscess|abscesses]]), [[osteomyelitis]] from [[bone]] involvement, [[prostatitis]] and [[epididymo-orchitis]] in males and [[tubo-ovarian abscess]] in females have been reported, disease recurrence. | ||
==Diagnosis== | ==Diagnosis== | ||
===History and symptoms=== | ===History and symptoms=== | ||
Symptoms of blastomycosis depends on the immune status of the individual, it presents as a flu like illness with fever, chills, myalgia, headache, and a nonproductive cough which resolves within days in | Symptoms of blastomycosis depends on the immune status of the individual, it presents as a flu-like illness with [[fever]], [[chills]], [[myalgia]], [[headache]], and a nonproductive [[cough]] which resolves within days in [[immunocompetent]] patients or as an acute illness resembling [[bacterial pneumonia]], with symptoms of [[high fever]], chills, a [[productive cough]], and [[pleuritis]] in [[immunocompromised]] individuals. Blastomycosis can affect other organs through hematogenous spread or lymphatics which includes [[skin]], [[bone]], genitourinary tract and [[brain]]. [[Skin]] lesions, usually appear as ulcerated lesions and bone lesions can lead to [[Osteomyelitis|osteomyelitis.]] | ||
===Physical examination=== | ===Physical examination=== | ||
Blastomycosis is disease of lung ,but it | Blastomycosis is a primary disease of [[lung]], but it may also affect other organs like [[skin]][[bone|bandone]]. Adetailed physical examination can guide towards the diagnosis. Lung examination findings include [[Percussion of the lungs|dullness to percussion]], and creased [[fremitus]]. Signs of [[Pleuritic chest pain|pleuritic]] involvement such as pleuritic [[chest pain]] and [[Pleural friction rub|pleural rub]] may be found. | ||
findings include dullness to percussion, | |||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
No | No radiographic findings are absolutely diagnostic of blastomycosis. Once suspected, the diagnosis of blastomycosis can usually be confirmed by demonstration of the characteristic broad-based budding [[organisms]] in [[sputum]] or [[tissues]] by [[KOH test|KOH prep]], [[cytology]], or [[histology]]. | ||
==X-ray | ==Chest X-ray == | ||
The findings are not consistent or highly specific. Alveolar infiltrates may be present but are not localized to a particular lobe. Consolidations with or without cavitations, small [[pleural effusion]]'s are relatively common. Sometimes, pulmonary nodules simulating tuberculosis or cancers may be present. Mediastinal lymph node enlargement is not a consistent finding | The findings on X-ray are not consistent or highly specific. [[Alveolar]] infiltrates may be present but are not localized to a particular [[lobe]]. [[Consolidation (medicine)|Consolidations]] with or without [[Cavitation|cavitations]], small [[pleural effusion]]'s are relatively common. Sometimes, [[Pulmonary nodule|pulmonary nodules]] simulating [[Tuberculosis, pulmonary|tuberculosis]] or [[Lung cancer|cancers]] may be present. [[Mediastinal]] [[lymph node]] enlargement is not a consistent finding but may be found occasionally. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
As per the guidelines given by the Infectious Diseases Society of America the appropriate regimen must be guided by the clinical form and severity of disease, as well as the immune status of patient and toxicity of antifungal agents. Only asymptomatic infections are left | The mainstay of treatment is [[antifungals]]. As per the current guidelines given by the Infectious Diseases Society of America, the appropriate regimen must be guided by the clinical form and severity of disease, as well as the immune status of patient and [[toxicity]] of [[Antifungals|antifungal agents]]. Only asymptomatic infections are left untreated, otherwise, all cases need therapy. [[Itraconazole]] given orally is the treatment of choice for most forms of the disease. Cure rates are high, and the treatment over a period of months is usually well tolerated. [[Amphotericin B]] is considerably more toxic, and is usually reserved for critically ill patients and those with [[central nervous system disease]].<ref name="pmid18462107">{{cite journal| author=Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG et al.| title=Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2008 | volume= 46 | issue= 12 | pages= 1801-12 | pmid=18462107 | doi=10.1086/588300 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18462107 }} </ref> | ||
* Immuno-competent patient.(Non-Life threatening infection) | * Immuno-competent patient. (Non-Life threatening infection): Drug of choice in this cases is usually [[Itraconazole]] or [[Amphotericin B|Lipid Amphotericin B]]. Alternatively, daily [[fluconazole]] or [[ketaconazole]] may also be used. | ||
* [[Immunocompetent]] patient. (Life-threatening infection): [[Pulmonary]] cases - These warrant treatment primarily with [[Amphotericin B|Lipid Amphotericin B]] or [[Amphotericin B|Deoxycholate Amphotericin B]]. Once the condition has been stabilized the patient may be switched to oral [[Itraconazole]] therapy. Disseminated cases - Drug of choice is same, however, patients nontolerant to [[Amphotericin B]] can be treated with [[fluconazole]] or [[Itraconazole]]. | |||
* | * [[Immunocompromised]] patients: All patients warrant treatment with [[Amphotericin B|Lipid Amphotericin B]] as the drug of choice and [[Itraconazole]] once the disease has shown clinical improvement. | ||
==Primary Prevention== | ==Primary Prevention== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Blastomycosis is a fungal infection caused by the organism Blastomyces dermatitidis. It is endemic in portions of the Mississippi river and Ohio river basins and around the Great Lakes in North America, and causes clinical symptoms such as fever, productive cough and myalgia. The symptoms, develop between 3 to 15 weeks after exposure. Majority of the cases are self-limiting with out any progression. Antifungals are used to treat if symptoms persist for more than 4 weeks. Prognosis is good depending on the immune status of the individual.[1][2]
Historical Perspective
Blastomycosis was first described in detail by Thomas Casper Gilchrist in 1894.
Pathophysiology
Infection occurs by inhalation of the conidia from its natural soil habitat. It has an average incubation period of 3 weeks to 3 months after exposure. Once inhaled, they multiply in lungs and initiate neutrophilic response with subsequent cell-mediated immune response leading to suppurative tissue destruction in lungs, and may disseminate through blood and lymphatics to other organs including skin, bone, genitourinary tract, and brain. The characteristic histopathological findings on sputum microscopy is the multi nucleated yeast form (budding).[3][4][5]
Causes
Blastomycosis is a fungal infection caused by Blastomyces dermatitidis.[6]
Differentiating Blastomycosis from other Diseases
Blastomycosis presents as a mild flu-like illness and needs to be differentiated from other fungal disorders like coccidioidomycosis, histoplasmosis, aspergillosis, pneumocystis pneumoniasandporotrichosis.
Epidemiology and Demographics
Blastomycosis is endemic in the Mississippi river and Ohio river basins and around the Great Lakes in United States.The annual incidence is less than 1 case per 100,000 people in Mississippi, Louisiana, Kentucky, and Arkansas.[7][8]
Risk Factors
The risk factors are not well established for the acquisition of blastomycosis even in endemic areas. However, studies point out the role of moist soil rich in organic debris as a source of transmission.
Screening
According to the centers for disease control and prevention screening for blastomycosis is not recommended.
Natural History, Complications and Prognosis
Blastomycosis is a granulomatous disease entity, that can produce a wide range of signs and symptoms, but in most cases, it is a mild illness. The symptoms include fever, productive cough, hemoptysis and weight loss. If left untreated, a significant proportion of these cases may further disseminate to other body parts, most commonly to skin, followed by bone and joint, genitourinary system and other sites in the body (Nervous systemlandymphatics). The route of spread is most commonly either hematogenous or lymphatic. Prognosis of the individual depends on the immune status of the individual and treatment, usually good in immunocompetent patients with treatment, on contrast prognosis is poor in patients even with treatment in immuno-compromised individuals. Complications that may develop with blastomycosis include cutaneous involvement can cause large sores with pus (abscesses), osteomyelitis from bone involvement, prostatitis and epididymo-orchitis in males and tubo-ovarian abscess in females have been reported, disease recurrence.
Diagnosis
History and symptoms
Symptoms of blastomycosis depends on the immune status of the individual, it presents as a flu-like illness with fever, chills, myalgia, headache, and a nonproductive cough which resolves within days in immunocompetent patients or as an acute illness resembling bacterial pneumonia, with symptoms of high fever, chills, a productive cough, and pleuritis in immunocompromised individuals. Blastomycosis can affect other organs through hematogenous spread or lymphatics which includes skin, bone, genitourinary tract and brain. Skin lesions, usually appear as ulcerated lesions and bone lesions can lead to osteomyelitis.
Physical examination
Blastomycosis is a primary disease of lung, but it may also affect other organs like skinbandone. Adetailed physical examination can guide towards the diagnosis. Lung examination findings include dullness to percussion, and creased fremitus. Signs of pleuritic involvement such as pleuritic chest pain and pleural rub may be found.
Laboratory Findings
No radiographic findings are absolutely diagnostic of blastomycosis. Once suspected, the diagnosis of blastomycosis can usually be confirmed by demonstration of the characteristic broad-based budding organisms in sputum or tissues by KOH prep, cytology, or histology.
Chest X-ray
The findings on X-ray are not consistent or highly specific. Alveolar infiltrates may be present but are not localized to a particular lobe. Consolidations with or without cavitations, small pleural effusion's are relatively common. Sometimes, pulmonary nodules simulating tuberculosis or cancers may be present. Mediastinal lymph node enlargement is not a consistent finding but may be found occasionally.
Treatment
Medical Therapy
The mainstay of treatment is antifungals. As per the current guidelines given by the Infectious Diseases Society of America, the appropriate regimen must be guided by the clinical form and severity of disease, as well as the immune status of patient and toxicity of antifungal agents. Only asymptomatic infections are left untreated, otherwise, all cases need therapy. Itraconazole given orally is the treatment of choice for most forms of the disease. Cure rates are high, and the treatment over a period of months is usually well tolerated. Amphotericin B is considerably more toxic, and is usually reserved for critically ill patients and those with central nervous system disease.[9]
- Immuno-competent patient. (Non-Life threatening infection): Drug of choice in this cases is usually Itraconazole or Lipid Amphotericin B. Alternatively, daily fluconazole or ketaconazole may also be used.
- Immunocompetent patient. (Life-threatening infection): Pulmonary cases - These warrant treatment primarily with Lipid Amphotericin B or Deoxycholate Amphotericin B. Once the condition has been stabilized the patient may be switched to oral Itraconazole therapy. Disseminated cases - Drug of choice is same, however, patients nontolerant to Amphotericin B can be treated with fluconazole or Itraconazole.
- Immunocompromised patients: All patients warrant treatment with Lipid Amphotericin B as the drug of choice and Itraconazole once the disease has shown clinical improvement.
Primary Prevention
Avoiding travel to areas where the infection is known to occur may help prevent exposure to the fungus, but this may not always be possible.
References
- ↑ "CDC - Symptoms of Blastomycosis". Retrieved 22 November 2013.
- ↑ Ryan KJ; Ray CG (editors) (2004). Sherris Medical Microbiology (4th ed. ed.). McGraw Hill. pp. pp.676&ndash, 8. ISBN 0838585299.
- ↑ Saccente M, Woods GL (2010). "Clinical and laboratory update on blastomycosis". Clin. Microbiol. Rev. 23 (2): 367–81. doi:10.1128/CMR.00056-09. PMC 2863359. PMID 20375357.
- ↑ Smith JA, Riddell J, Kauffman CA (2013). "Cutaneous manifestations of endemic mycoses". Curr Infect Dis Rep. 15 (5): 440–9. doi:10.1007/s11908-013-0352-2. PMID 23917880.
- ↑ Koneti A, Linke MJ, Brummer E, Stevens DA (2008). "Evasion of innate immune responses: evidence for mannose binding lectin inhibition of tumor necrosis factor alpha production by macrophages in response to Blastomyces dermatitidis". Infect. Immun. 76 (3): 994–1002. doi:10.1128/IAI.01185-07. PMC 2258846. PMID 18070904.
- ↑ DiSalvo, A.F. (1992). Al-Doory, Y., DiSalvo, A.F., ed. Ecology of Blastomyces dermatitidis. Plenum. pp. 43–73.
- ↑ Baumgardner DJ, Buggy BP, Mattson BJ, Burdick JS, Ludwig D (1992). "Epidemiology of blastomycosis in a region of high endemicity in north central Wisconsin". Clin. Infect. Dis. 15 (4): 629–35. PMID 1420675.
- ↑ Khuu D, Shafir S, Bristow B, Sorvillo F (2014). "Blastomycosis mortality rates, United States, 1990-2010". Emerging Infect. Dis. 20 (11): 1789–94. doi:10.3201/eid2011.131175. PMC 4214285. PMID 25339251.
- ↑ Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG; et al. (2008). "Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America". Clin Infect Dis. 46 (12): 1801–12. doi:10.1086/588300. PMID 18462107.