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  • • Inhalation of spores causes germination, caseation; occasionally infection occurs through skin inoculation

    • Manifestations can occur in many organs

    • -Lungs

      -Skin

      -Bone

      -Genitourinary tract

      -CNS

    • Pulmonary infection

    • -Predilection for upper lobes

      -Hilar mediastinal adenopathy unusual (unlike histoplasmosis and coccidioidomycosis)

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Epidemiology

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  • • Pulmonary fungal infections are rising due to widespread use of broad-spectrum antibiotics, immunosuppressive drugs, and HIV

    • Occur anywhere in world, some with characteristic endemic areas

    Blastomycosis dermatitidis found in warm, wet, nitrogen-rich soil in east, Midwest, and south (except Florida and New England)

    • -Characteristically in males (10:1 male:female ratio), from 30- to 60-years-old generally

      -Risk factors include poor hygiene, poor housing

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Symptoms and Signs

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  • Pulmonary infection: Asymptomatic or flu-like symptoms (cough, weight loss, pleuritic pain, fever, hemoptysis, erythema nodosum)

    • Evidence of pneumonia or pleurisy may occur

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Imaging Findings

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  • Chest film: Homogeneous, patchy consolidation in nonsegmental distribution with pleural effusions, cavitation (15-35%)

    • -Pulmonary masses may mimic malignancy

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  • • No accurate skin test

    • Culture and identification of yeast form

    • Culture of myceal form hazardous

    • Yeast form found in sputum (33%), bronchoalveolar lavage (38%), biopsies (21%), fine-needle aspiration (7%)

    • Yeast does not have large capsule (unlike Cryptococcus), does not grow intracellulary (unlike histoplasmosis)

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  • • Chest x-ray

    • Chest CT scan

    • Sputum microscopy and culture

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  • • No treatment needed for limited disease and asymptomatic

    • Antifungals first-line therapy

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Surgery

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  • • Resect involved tissue, likely lobectomy

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Indications

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  • • Rarely necessary except when malignancy cannot be ruled out

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Medications

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  • • Nonmeningeal disease: Itraconazole for 3 mos (> 80% response)

    • Meningeal disease or failed therapy: Amphotericin B

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References

Piarrouz R et al: Assessment of preemptive treatment to prevent severe candidiasis in critically ill surgical patients. Crit Care Med 2004;32:2443.
Walsh TJ et al: Voriconazole compared with liposomal amphotericin B for empirical antifungal therapy in patients with neutropenia and persistent fever. NEJM 2002;346:225.  [PubMed: 11807146]

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