Disseminated Blastomycosis
A 39-year-old man presented with acute hemoptysis and chills. Computed tomography (CT) of his chest showed an infiltrate in the right upper lobe (Panel A), and he was treated with levofloxacin. One month after this presentation, his 5-year-old son pulled on his left ring finger, which caused pain and swelling. On examination, the finger was erythematous, swollen, and tender (Panel B); a radiograph showed evidence of osteomyelitis. Eight weeks after the initial chest CT, a follow-up chest CT scan showed persistent infiltrate in the right upper lobe. Purulent fluid was found around the proximal phalanx and was drained. Staining with a potassium hydroxide preparation revealed yeast with broad-based budding (Panel C). Cultures of the purulent fluid specimens and sputum samples grew Blastomyces dermatitidis. History taking at this time revealed that the patient had gone hiking in northern Minnesota during the preceding summer. The events in the patient’s illness suggest that acquisition of B. dermatitidisoccurred in northern Minnesota and manifested as the initial pulmonary disease and subsequent hematogenous spread to a traumatized digit, leading to osteomyelitis and abscess. A diagnosis of disseminated blastomycosis was made, and the patient was treated with oral itraconazole for 1 year, by which time the finger had healed and the pulmonary infiltrate had resolved.
