Blastomyces dermatitidis is a dimorphic fungus found in Canada, the United States and many other countries. Inhaled fungal spores can infect the lungs and spread to other parts of the body. Blastomycosis is one fungus that grows inside the body in yeast form. These yeast cells can cause severe, invasive infection that is sometimes fatal because the diagnosis is not made and effective treatment is not prescribed. The yeast cells spread like cancer cells through the blood stream and can grow in every body tissue.
Infection by blastomyces is difficult to recognize even in areas where physicians are aware of this problem. Infection usually begins in the respiratory tract. The illness resembles influenza or pneumonia. Acute blastomycosis is often misdiagnosed as bacterial pneumonia and is treated with antibiotics with no benefit. Lung lesions that resemble tuberculosis or cancer may appear and lead to further misdiagnosis and inappropriate treatment. Lesions in the trachea and larynx are nodular and may be diagnosed as squamous cell carcinoma unless a biopsy is performed and interpreted correctly.
Blastomycosis can spread to any tissue of the body.
In an area, where blastomycosis was known, only 18% of 123 patients at the University of Mississippi Medical Center (Jackson, MS) were correctly diagnosed at the initial patient evaluation. Pneumonia (40%), malignant tumors (16%) and tuberculosis (14%) were the most common misdiagnoses. The false first impression frequently resulted in unnecessary surgeries or treatment delays, with patients receiving inefficient antibiotic therapy sometimes for months. Sometimes the diagnosis was made in the autopsy room.
Adapted from The US CDC Description of Blastomycosis
Clinical Features Infection presents as a flu-like illness with fever, chest pain, cough, aching, fatigue, weight loss. Some patients fail to recover and develop chronic pulmonary infection or widespread disseminated infection (affecting the skin, bones, and genitourinary tract). Occasionally, the brain becomes infected. Infection can lead to permanent lung damage with chronic disease.
Transmission Inhalation of airborne spores after disturbance of contaminated soil.
Risk Groups Persons in areas with with exposures to wooded, lakes, rivers, beaver dams and construction sites (e.g., farmers, construction and forestry workers, hunters, hikers and campers).
A standard recommendation for quick diagnosis is sputum microscopy -- a simple and inexpensive test that in experienced hands can permit quick diagnosis patients with a pneumonic presentation. The technique is to place a sample of freshly expectorated sputum on a slide and digest it with drops of potassium hydroxide. Cover it with a cover slip and examine it under a microscope. A standard textbook describes yeasts, 8-20 micrometers in size, with single, broad-based buds, double refractile walls, and multiple nuclei. I discovered that sputum containing this organisms had white clumps and strings that contained yeast cells. The size variation was much greater than the textbooks describe and that yeast cells transform within hours of cooling and disappear in 24 - 48 hours. Specimens transported to a lab were never properly handled and the diagnosis was never made by inexperienced microscopes.
I diagnosed my own infection by sputum microscopy and developed a novel 2-slide culture method, described in this report.
A profusion of fungi exists in the environment. Some fungi are able to cause an invasive infection in otherwise healthy individuals. Other fungi are opportunistic fungi that become invasive when immune defenses are compromised. Diagnosis of fungal infection is difficult. There are many problems when you try to connect a test result to a disease. Fungi are so abundant and there are so many varieties in every environment that it is seldom easy to pick just one cause among many. Fungi are inhaled and ingested. Foods always contain fungal spores and actively growing molds. Attempts to culture fungi often fail; only a small number grow in the culture media commonly used. Some new methods of detecting fungal DNA may be useful but development of reliable tests is slow and expensive.
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