Blastomycosis in a Young African Man Presenting with a Pleural Effusion

Abstract

in a young African man presenting with a pleural effusion. Can Respir J 2006;13(8):441-444.Blastomyces dermatitidis is a dimorphic fungus endemic to northwestern Ontario, Manitoba and some parts of the United States. The fungus is also endemic to parts of Africa. Pulmonary and extrapulmonary findings of a 24-year-old African man who presented with weight loss, dry cough and chronic pneumonia not resolving with antibiotic treatment are presented. The unusual occurrence of pulmonary blastomycosis associated with skin lesions and a moderate pleural effusion is reported. CASE PRESENTATIONA 24-year-old previously healthy man from Tanzania presented with a three-month history of dry cough, fatigue and fever. He was treated empirically for a community-acquired pneumonia; however, after two courses of antibiotic treatment he did not improve clinically, and had a worsening chest radiograph showing a large unilateral pleural effusion. His vital signs, however, were normal. Other clinical features included a 14 kg weight loss and scaling papulonodular skin lesions on the nose ( Figure 1A), right hand ( Figure 1B) and right forearm. In addition to the skin lesions, he also had a raised subcutaneous nodular lesion on his left buttock and left upper arm suppuration. InvestigationsOn admission, the patient's white blood cell count was 13.5×10 9 /L, hemoglobin level was 117 g/L, platelet count was 584×10 9 /L and serum albumin level was 30 g/L. Electrolytes, renal function and liver enzyme levels were normal. HIV serology was negative. Sputum initially showed heavy growth of normal respiratory flora; no acid-fast bacilli were seen. A pigtail catheter was inserted to drain the right pleural fluid which showed a pH of 8, glucose level of 5.6 mmol/L, total protein concentration of 62 g/L and lactate dehydrogenase level of 152 U/L. Pleural fluid white blood cell differential showed 31% neutrophils, 61% lymphocytes, 7% monocytes and 1% eosinophils. The pleural fluid was consistent with an exudate. Bronchoscopy washings were negative for Gram and fungal stains. Radiographs of the pelvis and femur were normal. A plain chest radiograph showed a moderate-sized right pleural effusion on posteroanterior view (Figure 2A) and some ill-defined soft tissue nodules in the lateral aspect of the left upper lung zone. An enhanced axial computed tomography of the thorax in the mediastinal window settings confirmed a moderate-sized right pleural effusion with multiple well-defined soft tissue nodules over the parietal pleura projecting into the pleural cavity, which was better seen over the diaphragmatic surface ( Figure 2B). No significant mediastinal lymphadenopathy was noted. On the lung window settings, centrilobular nodules in a tree-in-bud pattern at the apicoposterior segment of the left upper lobe were present. Consolidative changes of the lateral segment of the right middle lobe and the right lower lobe were also seen. Hospital courseThe patient was from an area endemic for HIV and tuberculosis, and had significant weight loss, mild anem...

Burden of serious fungal infections in Tanzania

“…A previous large systematic review on blastomycosis from 18 African countries reported a total of 81 cases, one of which was from Tanzania showing that the lack of epidemiological data does not exclude the presence of blastomycosis in Tanzania. Also, a case report from Canada reported a Tanzanian expatriate diagnosed with blastomycosis . As discussed above, in this case report, the patient had been previously treated empirically for tuberculosis before being diagnosed with blastomycosis.…”

“…Assuming that 50% of all admitted patients in Tanzania have febrile illness, we estimated 135 cases of histoplasmosis in 2012 at a rate of 0.31 per 100 000 person‐years (Table ). Apart from case reports, no reliable epidemiological data exist for IA blastomycosis, mucormycosis or fungal keratitis in Tanzania and in sub‐Saharan Africa …”

The Basketball Player With Back Pain

“…Additionally, from our review of the literature, no cases of blastomycosis have been reported from Kenya or Sudan, although a few have been reported in Rwanda, Tanzania, and Uganda. [11][12][13] This case underscores the need to maintain a high index of suspicion for B. dermatitidis in patients with vertebral osteomyelitis and paravertebral fluid collections, particularly since vertebral tuberculosis can manifest similarly. In this case, despite the patient's exposure to an area hyperendemic for blastomycosis, the correct diagnosis was made only after there was progression of signs and symptoms while on antituberculous therapy.…”

Re-drawing the Maps for Endemic Mycoses

“…Blastomyces dermatitidis , including the more recently described cryptic species B. gilchristi (together referred to herein as B. dermatitidis species complex), and B. helicus cause disease in humans and animals via inhalation of airborne spores [ 6 , 14 , 164 – 171 ]. The mycelial form of the fungus primarily dwells in wooded land with damp soil near lakes, waterways and rivers [ 164 , 167 , 171 – 175 ]. Excavation and construction in endemic areas have been identified as risk factors for disease acquisition [ 176 ].…”

“…Excavation and construction in endemic areas have been identified as risk factors for disease acquisition [ 176 ]. B. dermatitidis species complex is endemic in the mid-west, southeast, east and south-central USA; northwest Ontario, Quebec, Manitoba and Saskatchewan in Canada; central, eastern and southern Africa; and India [ 6 , 7 , 28 , 164 , 166 , 167 , 177 – 185 ]. Figure 3 shows the geographic distribution of B. dermatitidis species complex worldwide.…”