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Stephen Gislason MD

Blastomycosis: the nightmare at the cottage

JAKE MACDONALD, adapted from his McLean's Magazine Article Aug 2006

How do you fight a disease when so few doctors know about it?

A lot of boys would envy Kevin Schneider. A freckle-nosed and fearless 13-year-old, Kevin lives on the edge of a beautiful lake near Minaki, in northwestern Ontario. But living in the woods of northwestern Ontario can have its risks. Last May, Kevin was on his way home from school when his chest began aching. When his parents took him to emergency, the doctors diagnosed the problem as inflammation of the rib cartilage -- ordinary growing pains treatable with Tylenol.

But the pains persisted, for days and then weeks, and tests showed nothing. When lab results finally revealed traces of a streptococcal infection, his family doctor put him on penicillin, but that didn't help, nor did other antibiotics designed for fighting pneumonia. By mid-July, with Kevin going downhill, losing weight and experiencing so much pain he was having trouble getting to sleep, his mother, Jane Campbell, asked that specialists be called in, and when Kenora pediatrician Dr. Peter Harland saw Kevin, things began happening quickly. "He ordered tests, like right now, and said, 'Don't go away, because I need to talk to you as soon as we get the results.' "

This time, X-rays showed that Kevin's right chest was full of fluid, a serious and possibly life-threatening development. Harland ordered a round of heavy antibiotics. Kevin's mother's voice still shakes with controlled emotion when she relates what happened next. "Dr. Harland said we had to consider the possibility that Kevin had blastomycosis."

Blastomycosis is such a rare disease that many doctors -- even diagnostic hotshots from big-city emergency rooms -- may never have heard of it. But in the Lake of the Woods region, "blasto" has grown into a bogeyman that threatens to take at least some of the joy out of gardening, tree planting and boyish adventuring in the woods. A fungus called Blastomyces dermatitidis thrives in the acidic soil, and its spores, when inhaled, can thrive in the dark, moist interior of the human body, where they produce a yeast infection that can kill the victim if left untreated. "Blastomycosis can be found over much of North America," says Lyle Wiebe, environmental health program manager at the Northwestern Health Unit in Kenora. "Manitoba gets a few cases every year, and Timmins, Thunder Bay and Georgian Bay have all had small outbreaks. But the Lake of the Woods region has the dubious distinction of being the global hot spot."

In the summer of 2004, an 11-year-old boy from Winnipeg, plus his dog, contracted blastomycosis after doing some cleanup under his family's Kenora-area cottage. Veterinarians diagnosed the dog, which lost an eye, but months passed before medical specialists diagnosed the boy. By then, the infection had eaten away part of his skull. He survived, but had to undergo reconstructive bone surgery. In other cases, patients haven't been diagnosed until they reached the autopsy table.

Dr. John Embil of the Winnipeg Health Sciences Centre says he is ambivalent about publicizing the outbreak. "On the one hand, northwestern Ontario is a beautiful part of the world. This is a rare disease and I don't want to diminish anyone's enjoyment of the outdoors. On the other hand, I encourage people to take precautions when working in places where they might encounter the fungus." Embil recommends wearing a dust mask, gloves, boots and coveralls when working in the woods, digging holes, gardening, cleaning up old woodpiles or working underneath buildings. "I ask people to use common sense. It's not a good idea to be inhaling any kind of airborne dust."

The spores, once inhaled, may lodge inside the human body for up to 120 days before producing symptoms like sharp chest pain, night sweats and loss of appetite. To complicate matters, blastomycosis can easily be mistaken for pneumonia, tuberculosis and even lung cancer. In Kevin Schneider's case, his doctors were initially deceived because the disease was hiding behind his lung pleura -- the lining between the lungs and chest wall. His pediatrician sent him to Winnipeg's Health Sciences Centre, where surgeons drained his chest, took a biopsy and confirmed blastomycosis. His medical team put him on a six-month regime of a pricey drug called itraconazole, and now he's fully recovered.

Embil, who is widely regarded as the world expert on blastomycosis, says that Kevin Schneider was probably fortunate to have wound up in the Winnipeg hospital. "Front-line health professionals in this part of the country are becoming quite skilled at diagnosing and treating this disease. But it's less well-known elsewhere." Even with increasing awareness among doctors, one study indicated that only 18 per cent of blastomycosis victims were correctly diagnosed by front-line medical personnel.

The most worrisome scenario features tourists visiting the Lake of the Woods region, inhaling dermatitidis spores, and going home to Los Angeles or Vancouver or some other large city where the average doctor couldn't even spell blastomycosis, let alone diagnose it. Says Lyle Wiebe, "We may be dealing with a lot more cases than we know about."

Wiebe and his colleagues at the Northwestern Health Unit are lobbying the government of Ontario to put blastomycosis on the list of reportable diseases. "One of the important steps in fighting this is finding out how widespread it is. Right now, there's an awful lot we just don't know.”

Article from McLeans Magazine Aug 17 2006

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