Practice Guidelines for the Management of Patients with Blastomycosis

Abstract

Guidelines for the treatment of blastomycosis are presented; these guidelines are the consensus opinion of an expert panel representing the National Institute of Allergy and Infectious Diseases Mycoses Study Group and the Infectious Diseases Society of America. The clinical spectrum of blastomycosis is varied, including asymptomatic infection, acute or chronic pneumonia, and extrapulmonary disease. Most patients with blastomycosis will require therapy. Spontaneous cures may occur in some immunocompetent individuals with acute pulmonary blastomycosis. Thus, in a case of disease limited to the lungs, cure may have occurred before the diagnosis is made and without treatment; such a patient should be followed up closely for evidence of disease progression or dissemination. In contrast, all patients who are immunocompromised, have progressive pulmonary disease, or have extrapulmonary disease must be treated. Treatment options include amphotericin B, ketoconazole, itraconazole, and fluconazole. Amphotericin B is the treatment of choice for patients who are immunocompromised, have life-threatening or central nervous system (CNS) disease, or for whom azole treatment has failed. In addition, amphotericin B is the only drug approved for treating blastomycosis in pregnant women. The azoles are an equally effective and less toxic alternative to amphotericin B for treating immunocompetent patients with mild to moderate pulmonary or extrapulmonary disease, excluding CNS disease. Although there are no comparative trials, itraconazole appears more efficacious than either ketoconazole or fluconazole. Thus, itraconazole is the initial treatment of choice for nonlife-threatening non-CNS blastomycosis.

Production and Evaluation of Reagents for Detection of Histoplasma capsulatum Antigenuria by Enzyme Immunoassay

“…Four rabbits were injected intravenously with 1 ml each of whole, killed H. capsulatum yeast-phase cells on days 0, 1,4,8,10,15,18,23,29, and 32. After day 56, rabbits were boosted every 4 to 6 weeks by injecting a total of 1 ml of whole, killed H. capsulatum yeast-phase cells subcutaneously at four dorsal sites.…”

Systemic Blastomycosis Diagnosed by Prostate Needle Biopsy

“…Serologic and skin tests are non-invasive and rapid but are limited by sensitivity and specificity. 2,4,5,26,27 Antigen detection in urine or other body fluids for B. dermatitidis is reported as sensitive with high reproducibility however cross reactivity with other mycoses may prohibit clear diagnosis. [28][29][30] The WI-1 antigen based antibody test has good sensitivity and specificity but is not widely available.…”

“…A tissue biopsy should also be obtained in cases of secondary infection, and in these extrapulmonary cases the organisms are also visible on routine hematoxylin-eosin or Papanicolaou stains. 5,27,34 Chest radiography should be performed in every case of blastomycosis. 2 An additional diagnostic challenge to the clinician may be that blastomycosis has an expanding yet fairly well-defined area of endemicity.…”

“…Liposomal amphotericin could also be used in the event of nephrotoxicity. 27 Voriconazole appears promising targeting blastomycotic meningitis, with favorable pharmacokinetics, . Spiral chest CT with intravenous contrast bolus shows significant bilateral perihilar lymphadenopathy; numerous perivascular and perilymphatic nodular densities somewhat irregular in contour; scattered subpleural nodules; mild to moderate mediastinal adenopathy; small axillary lymph nodes present bilaterally; and a prominent left perihilar mass contiguous with hilar adenopathy.…”

Unexpected Blastomyces dermatitidis Etiology of Fungal Sinusitis and Erosive Palatal Infection in a Diabetic Patient

“…Fluconazole was sub-stituted for itraconazole within the step-down therapeutic component because the patient had poor oral intake and was less likely to tolerate and/or absorb itraconazole liquid formulation. Moreover, high-dose fluconazole regimens have been shown to be effective in the management of non-life-threatening blastomycosis (2,3). The patient exhibited significant clinical resolution of palatal findings following approximately 4 weeks of amphotericin B therapy.…”