1. Blastomycosis

2. History  43 male smoker 25 pack seen at OPD  Unresolving respiratory symptoms for 6/12  Chronic cough with green sputum  now repeated minimal hemoptysis  now repeated minimal hemoptysis  Fever with night sweating intermittent  Wt loss 45 lbs  SOBE mild effort

3. History  No orthopnea, PND or CP  No leg pain or swelling  NO CTD symptoms  No contact,travel  Works in courier service  No pets  PMH & PSH & FH :-ve

4. History  Trial of Abx 2 courses Amoxil 2 weeks & Gatifluxacine 3 months Amoxil 2 weeks & Gatifluxacine 3 months  no improvement  no improvement  Off work being symptomatic  Referred ? Malignancy

5. Examination  Afebrile RR 16 Sat 96% RA  BP 130/70 HR 80  No clubbing  Chest : minimal crackles Lt lower 1/3  CVS : N  ABD & LL N  No CTD signs

6. Investigations  CBC Coagulation N  BUN, Creat, lytes N  LFT N  UA N  CXR  Airspace disease lingula & LLL ?Lt hilar enlargement ?Lt hilar enlargement  CT Chest

7. Investigations  Bronchoscopy  N  BAL cytology  -ve for malignancy  Initial culture  strept & H.Inf  3 weeks after Bronch  new growth

9. Blastomycosis

10. Blastomycosis  Blastomyces dermatitidis is a dimorphic fungus  mycelial form at room temperature  mycelial form at room temperature & yeast form at body temperature. & yeast form at body temperature.  Etiology of spectrum of diseases that occur either in sporadic or epidemic cases.  2 serotypes : A antigen +ve or –ve {mainly in Africa}

11. Epidemiology  Estimating incidence has been difficult  lack of sensitive & specific diagnostic tests  lack of sensitive & specific diagnostic tests considerable number of cases are subclinical considerable number of cases are subclinical  Based on clinical reports of cases endemic areas are states bordering Mississippi & Ohio rivers states bordering Mississippi & Ohio rivers  Southeastern & South-central  Southeastern & South-central & states bordering the great lakes  Canadian provinces, Midwestern  Canadian provinces, Midwestern

12. Epidemiology  Environment is soil containing decayed vegetations or decomposed woods  Rain fall or proximity to water source maintaining humidity is a major factor  Those environmental factors are short lived

13. Presentations  Infection through inhalation of conidia from the ruptured mycelia.  Conidia then rapidly converts to yeast form which more resistant to phagocytosis.  Host defense is cellular  doesn't confer immunity or fasten recovery.  doesn't confer immunity or fasten recovery.

14. Presentations  General : fever, malaise,fatigue & Wt loss  Pulmonary : Acute resemble CAP Chronic might be mistaken for malignancy Reported cases  empyema & ARDS CXR  alveolar disease CXR  alveolar disease upper lobes predominance upper lobes predominance or Mass, miliary reticulonodular pattern or Mass, miliary reticulonodular pattern Cavitations & effusions are rare Cavitations & effusions are rare

15. Presentations  Cutaneous: 2 nd most common Isolated or concomitant with respiratory involvement Either verrucous or ulcerative lesions Aspirations or Bx will yield Dx  Osseous : both axial & peripheral bones radiological findings are non specific radiological findings are non specific Bx  granulomatous inflammation Bx  granulomatous inflammation

16. Presentations  CNS : Meningitis, abscess Ventricular fluid has a higher yield than LP Ventricular fluid has a higher yield than LP  GU : Prostatitis & epididmoorchitis  Rare : LN, Liver & spleen abscess ocular,adrenal, breast ocular,adrenal, breast Presenting with ITP, Immune hemolysis Presenting with ITP, Immune hemolysis Associated with TB, Histo & Coccidio Associated with TB, Histo & Coccidio

17. Presentations  Retrospective study In Manitoba Jan 1988  Dec 1999 Jan 1988  Dec 1999 Dx  clinically either pneumonia or skin lesions & isolation of fungus by culture or cytology & isolation of fungus by culture or cytology  143 patients 58.7% Manitoba resident & 41.3% Ontario resident & 41.3% Ontario resident  Mean Age 38+/- 20 M:F 65% Vs 35% CID May 2002 CID May 2002

18. Presentations  68% Manitoba residents have a +ve travel history of which 41% to Northwestern Ontario  Outdoor occupation 13.5% (occupation was available 138/143 patients ) (occupation was available 138/143 patients )  Annual incidence 0.62 per 100,000 Manitoba 7.1 per 100,000 Kenora ON 7.1 per 100,000 Kenora ON

20. Presentations  Manitoba incidence is half the incidence in endemic area Wisconsin & Mississippi  Kenora incidence 4 times other Manitoba or ON divisions.  Mortality rate 6.3% mainly respiratory failure Mortality was higher in patients with shorter symptoms before diagnosis Mortality was higher in patients with shorter symptoms before diagnosis

21. Diagnosis  Blastomyces is not a normal flora  either seeing or culturing it is reliable for Dx  either seeing or culturing it is reliable for Dx  Serology is not helpful because of cross reactivity with other fungi  epidemiological assessment  Skin testing  high false –ve results

22. Diagnosis  Retrospective study 119 patients  47% pulmonary involvement  Inclusion 1) Isolation from respiratory samples 1) Isolation from respiratory samples 2) Isolation from non respiratory sample 2) Isolation from non respiratory sample + clinical & radiological picture of pneumonia + clinical & radiological picture of pneumonia 3) Clinical & Radiological suspicion 3) Clinical & Radiological suspicion & +ve serology & +ve serology Chest Mar 2002 Chest Mar 2002

25. Diagnosis  High diagnostic yields from culture specimen &culturing different sources will increase yield  Increase number of specimens increase yield  Average time to confirm Dxby Culture  5 weeks  5 weeks

26. Diagnosis  KOH may provide faster & comparable yield to cultures  Serology yield 16-40%  Wet smear & cytology might be helpful in endemic areas endemic areas when starting treatment is urgent when starting treatment is urgent to avoid more invasive investigations to avoid more invasive investigations

27. Treatment  Spontaneous resolution is very uncommon  Untreated cases might have mortality 60%  No randomized trial comparing antifungal Rx  Rx selection depends on immune status & severity of infection & severity of infection Infectious dis clin 2003 Infectious dis clin 2003

28. Treatment  Immunocompromized with CNS,Respiratory failure or multioragn failure  Ampho B  Itraconazole is the drug of choice 200 mg. 6 months cure rate > 90% 6 months cure rate > 90%  Ketoconazole variable cure rates with higher CNS relapse with higher CNS relapse