Abstract
Background
Blastomycosis is an uncommon granulomatous infection caused by the thermally dimorphic fungus Blastomyces dermatitidis. The most frequent clinical infections involve the lung, skin, and bone. Pulmonary manifestations range from asymptomatic self-limited infection to severe diffuse pneumonia causing respiratory failure.
Objectives
To establish the clinical characteristics and outcomes of patients with pulmonary blastomycosis diagnosed at hospitals in Manitoba and northwestern Ontario, Canada.
Methods
A retrospective review of medical records was done for 318 patients with blastomycosis in these regions.
Results
The majority of patients were Caucasian (198 (62.5%) patients), male (193 (61%) patients), and residents of Ontario (209 (65.7%) patients). Most patients were treated in an inpatient hospital ward (266 (84%) patients) and survived (294 (92%) patients). Pulmonary involvement, either alone or associated with other sites, was present in 296 (93%) of the 318 patients; 22 (7%) patients had no evidence of pulmonary blastomycosis. The majority of patients had localized lung disease (1–3 quadrants on chest radiograph involved; 225 (82%) patients). Of 294 (92%) patients requiring hospitalization, 266 (90%) patients received all inpatient care on a general medical ward; 28 (10%) patients received some care in the intensive care unit (ICU). Factors associated with ICU admission included diffuse pulmonary disease (four quadrants involved on chest radiograph), diabetes, and prior use of antimicrobial therapy. Twenty-four (8%) patients died, and multivariate analysis showed that older age and Aboriginal ethnicity were the significant risk factors for death from blastomycosis.
Conclusion
Blastomycosis is a cause of serious, potentially life-threatening pulmonary infection in this geographic region.
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References
Medoff G, Painter A, Kobayashi GS. Mycelial-to-yeast phase transitions of the dimorphic fungi Blastomyces dermatitidis and Paracoccidiodes brasiliensis. J Bacteriol. 1987;169:4055–60.
Denton JF, McDonough ES, Ajello L, Ausherman RJ. Isolation of Blastomyces dermatitidis from soil. Science. 1961;133:1126–7. doi:10.1126/science.133.3459.1126.
Sarosi GA, Davies SF. Blastomycosis. Am Rev Respir Dis. 1979;120:911–38.
Lemos LB, Guo M, Baliga M. Blastomycosis: organ involvement and etiologic diagnosis. A review of 123 patients from Mississippi. Ann Diagn Pathol. 2000;4:391–406. doi:10.1053/adpa.2000.20755.
Chapman SW. Blastomyces dermatitidis. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, Bennett’s principles and practice of infectious diseases. 6th ed. Philadelphia: Elsevier; 2005. p. 3026–40.
Landis FB, Varkey B. Late relapse of pulmonary blastomycosis after adequate treatment with amphotericin B. Am Rev Respir Dis. 1976;113:77–81.
Laskey W, Sarosi GA. Endogenous activation in blastomycosis. Ann Intern Med. 1978;88:50–2.
Ehni W. Endogenous reactivation in blastomycosis. Am J Med. 1989;86:831–2. doi:10.1016/0002-9343(89)90483-X.
Crampton TL, Light RB, Berg GM, Meyers MP, Schroeder GC, Hershfield ES, et al. Epidemiology and clinical spectrum of blastomycosis diagnosed at Manitoba hospitals. Clin Infect Dis. 2002;34:1310–6. doi:10.1086/340049.
Meyer K, McManus EJ, Maki DC. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. N Engl J Med. 1993;329:1231–6. doi:10.1056/NEJM199310213291704.
Stelling CB, Woodring JH, Rehm SR, Hopper DW, Noble RC. Miliary pulmonary blastomycosis. Radiology. 1984;150:7–13.
Chapman SW, Lin AC, Hendricks KA, Nolan RL, Currier MM, Morris KR, et al. Endemic blastomycosis in Mississippi: epidemiological and clinical studies. Semin Respir Infect. 1997;12:219–28.
Pfister AK, Godwin AW, Squire EW, Ellison AB, Walker JH. Pulmonary blastomycosis: roentgenographic clues to the diagnosis. South Med J. 1966;59:1441–7. doi:10.1097/00007611-196612000-00012.
Thompson CA, McEachern R, Norman JR. Blastomycosis as an etiology of acute lung injury. South Med J. 1998;91:861–3.
Smith JD, Harris JS, Conant NF, Smith DT. An epidemic of North American blastomycosis. JAMA. 1955;158:641–6.
Tosh FE, Hammerman KJ, Weeks RJ, Sarosi GA. A common source epidemic of North American blastomycosis. Am Rev Respir Dis. 1974;109:525–9.
Proctor ME, Klein BS, Jones JM, Davis JP. Cluster of pulmonary blastomycosis in a rural community: evidence for multiple high-risk environmental foci following a sustained period of diminished precipitation. Mycopathologia. 2002;153:113–20. doi:10.1023/A:1014515230994.
Kepron MW, Schoemperlen CB, Hershfield ES, Zylak CJ, Cherniack RM. North American blastomycosis in Central Canada. Can Med Assoc J. 1972;106:243–6.
Sekhon AS, Bogorus MS, Sims HV. Blastomycosis: report of 3 cases from Alberta with a review of Canadian cases. Mycopathologia 1979;68:53–63. doi:10.1007/BF00490391.
Centers for Disease Control and Prevention (CDC). Blastomycosis—Wisconsin, 1986–1995. MMWR Morb Mortal Wkly Rep 1996;45:601–3.
Sarosi GA, Davies SF, Phillips JR. Self-limited blastomycosis: a report of 39 cases. Semin Respir Infect 1986;1:40–4.
Vasquez JE, Mehta JB, Agrawal R, Sarubbi FA. Blastomycosis in northeast Tennessee. Chest. 1998;114:436–43. doi:10.1378/chest.114.2.436.
International Classification of Diseases. International Classification of Diseases. 9th Revision. Clinical Modification. 4th ed. Los Angeles: Practice Management Information Corporation (PMIC); 1994.
Royal Commission on Aboriginal Peoples. Report of the Royal Commission on Aboriginal Peoples. Volume 1. Looking Forward, Looking Back. Ottawa: Canada Communication Group; 1996.
Dwight PJ, Naus M, Sarsfield P, Limerick B. An outbreak of human blastomycosis: the epidemiology of blastomycosis in the Kenora catchment region of Ontario, Canada. Can Commun Dis Rep. 2000;26:82–91.
Morris SK, Brophy J, Richardson SE, Summerbell R, Parkin PC, Jamieson F, et al. Blastomycosis in Ontario, 1994–2003. Emerg Infect Dis. 2006;12:274–9.
Statistics Canada. Census of Population. 2001. http://www12.statcan.ca/english/census01/home/index.cfm, accessed July 28, 2005.
Lemos LB, Baliga M, Guo M. Blastomycosis, the great pretender can also be an opportunist. Initial clinical diagnosis and underlying disease in 23 patients. Ann Diagn Pathol. 2002;6:194–203. doi:10.1053/adpa.2002.34575.
Klein BS, Vergeront JM, Weeks RJ, Kumar UN, Mathai G, Varkey B, et al. Isolation of Blastomyces dermatitidis in soil associated with a large outbreak of blastomycosis in Wisconsin. N Engl J Med. 1986;314:529–34.
Mody CH, Warren PW. Host defense of pulmonary mycosis. Can J Infect Dis. 1999;10:147–55.
Duttera MJ, Osterhout S. North American blastomycosis: a survey of 63 cases. South Med J. 1969;62:295–301.
Abernathy RS. Clinical manifestations of pulmonary blastomycosis. Ann Intern Med. 1959;51:707–27.
Brown LR, Swensen SJ, Van Scoy RE, Prakash UB, Coles DT, Colby TV. Roentgenologic features of pulmonary blastomycosis. Mayo Clin Proc. 1991;66:29–38.
Sheflin JR, Campbell JA, Thompson GP. Pulmonary blastomycosis: findings on chest radiographs of 63 patients. AJR Am J Roentgenol. 1990;154:1177–80.
Rabinowitz JG, Busch J, Buttran WR. Pulmonary manifestations of blastomycosis: radiological support of a new concept. Radiology. 1976;120:25–32.
Armstrong JD. Common fungal diseases of the lungs III: blastomycosis. Radiol Clin North Am. 1973;11:169–73.
Cush R, Light RW, George RB. Clinical and roentgenographic manifestations of acute and chronic blastomycosis. Chest. 1976;69:345–9. doi:10.1378/chest.69.3.345.
Davies SF, Sarosi GA. Epidemiological and clinical features of pulmonary blastomycosis. Semin Respir Infect. 1997;12:206–18.
De Groote MA, Bjerke R, Smith H, Rhodes LV. Expanding epidemiology of blastomycosis: clinical features and investigation of 2 cases in Colorado. Clin Infect Dis. 2000;30:582–4. doi:10.1086/313717.
Centers for Disease Control and Prevention (CDC). Blastomycosis acquired occupationally during prairie dog relocation–Colorado, 1998. MMWR Morb Mortal Wkly Rep. 1999;48:98–100.
Baumgardner DJ, Halsmer SE, Egan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. Wilderness Environ Med. 2004;15:250–6.
Chapman SW, Bradsher RW, Campbell GD, Pappas PG, Kauffman CA. Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America. Clin Infect Dis. 2000;30:679–83. doi:10.1086/313750.
Krafft P, Fridrich P, Pernerstorfer T, Fitzgerald RD, Koc D, Schneider B. The acute respiratory distress syndrome: definitions, severity and clinical outcome. An analysis of 101 clinical investigations. Intensive Care Med. 1996;22:519–29.
Luhr OR, Antonsen K, Karlsson M, Aardal S, Thorsteinsson A, Frostell CG, et al. Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark, and Iceland. Am J Respir Crit Care Med. 1999;159:1849–61.
Cano MV, Ponce-De-Leon GF, Tippen S, Lindsley MD, Warwick M, Hajjeh RA. Blastomycosis in Missouri: epidemiology and risk factors for endemic disease. Epidemiol Infect. 2003;131:907–14. doi:10.1017/S0950268803008987.
Muller LM, Gorter KJ, Hak E, Goudzwaard WL, Schellevis FG, Hoepelman AI, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clin Infect Dis. 2005;41:281–8. doi:10.1086/431587.
Rajagopalan S. Serious infections in elderly patients with diabetes mellitus. Clin Infect Dis. 2005;40:990–6. doi:10.1086/427690.
Arvanitakis C, Sen SK, Magnin GE. Fulminating fatal pneumonia due to blastomycosis. Am Rev Respir Dis. 1972;105:827–31.
Atkinson JB, McCurley TL. Pulmonary blastomycosis: filamentous forms in an immunocompromised patient with fulminating respiratory failure. Hum Pathol. 1993;14:186–8.
Callaway JJ. Adult respiratory distress syndrome caused by blastomycosis infection. Mayo Clin Proc. 1986;61:75.
Evans ME, Haynes JB, Atkinson JB, Delvaux TC, Kaiser AV. Blastomyces dermatitidis and the adult respiratory distress syndrome. Case reports and review of the literature. Am Rev Respir Dis. 1992;126:1099–102.
Griffith JE, Campbell GD. Acute miliary blastomycosis presenting as fulminating respiratory failure. Chest. 1979;75:630–2. doi:10.1378/chest.75.5.630.
MacDonald D, Alguire PC. Adult respiratory distress syndrome due to blastomycosis during pregnancy. Chest. 1990;98:1527–8. doi:10.1378/chest.98.6.1527.
Mukkamala R, Mehta JB, Myers JW, Cole CP. Pulmonary blastomycosis with acute respiratory failure as predominant clinical feature. South Med J. 1997;90:847–50. doi:10.1097/00007611-199708000-00017.
Mundey K, Varkey B, Van Ruiswyk J, Yang F, Schapira RM. Adult respiratory distress syndrome from blastomycosis: a case report. Wisconsin Med J. 2001;100:40–2.
Renston JP, Morgan J, DiMarco AF. Disseminated miliary blastomycosis leading to acute respiratory failure in an urban setting. Chest. 1992;101:1463–5.
Skillrud DM, Douglas WW. Survival in acute respiratory distress syndrome caused by blastomycosis infection. Mayo Clin Proc. 1995;60:266–9.
Thiele JS, Buechner HA, Deshotels SJ. Blastomycosis and the adult respiratory distress syndrome. J La State Med Soc. 1994;136:38–40.
Acknowledgments
The authors thank the following for their invaluable assistance in this project: the Medical Records Departments at the Lake of the Woods District Hospital, Kenora, Ontario; Brandon General Hospital, Brandon, Manitoba; and the following Winnipeg hospitals: Victoria General Hospital, Grace General Hospital, Seven Oaks General Hospital, Concordia General Hospital, St. Boniface General Hospital, and Health Sciences Centre. The authors acknowledge the assistance of Ms. Carolyn Garlinski (manuscript preparation) and Ms. Debbie Ormiston (data base management), and Ms. Maryanne Kennedy, Ms. Lorraine Kuzyk, and Ms. Pam Schille, (data collection). The authors thank Dr. Ethan Rubenstein, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, for manuscript review and helpful comments.
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Kralt, D., Light, B., Cheang, M. et al. Clinical Characteristics and Outcomes in Patients with Pulmonary Blastomycosis. Mycopathologia 167, 115–124 (2009). https://doi.org/10.1007/s11046-008-9163-7
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DOI: https://doi.org/10.1007/s11046-008-9163-7