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

Abstract

We present what is believed to be the initial report of hard-palate infection caused by Blastomyces dermatitidis. The organism was cultivated from biopsy material obtained from a diabetic patient presenting with complaints of headache and malaise. Radiologic findings revealed a malignant-appearing soft-tissue mass with paranasal sinus base destruction. CASE REPORTA 79-year-old female presented for evaluation of a 4-to 5-day history of malaise and bilateral frontal lobe headache. Associated pain was characterized as moderate to severe. The patient was withdrawn and uncooperative during the examination. Weakness, dizziness, loss of appetite, and dysphagia also characterized the course of illness. Family members intimated that the patient had lost 30 to 40 pounds over the previous month. Past medical history was significant for type 2 diabetes mellitus, aortic valve replacement, depression, osteoarthritis, and hyperlipidemia. The patient was a nonsmoker and did not consume alcohol. No history of chronic headaches, cerebrovascular accident, transient ischemic attack, and psychiatric or neurologic maladies was revealed. At the time of presentation, the patient resided in a Wisconsin assisted-living facility. The patient was also a past resident of Tennessee, though the timing of this was unclear.Vital signs were stable upon presentation (temperature, 98.3°F; heart rate, 67 beats per min; blood pressure, 143/66), with the exception of slight tachypnea (20 inhalations per min). Pulse oximetry was 98% on 2 liters of supplemental oxygen. A chest X-ray indicated mild chronic obstructive pulmonary disease without acute disease. The patient had elevated laboratory values for peripheral leukocytes (15,800/l, with increased neutrophils [79.0%] and decreased lymphocytes [11.0%] upon differential), serum glucose (226 mg/dl; upper limit of normal, 99 mg/dl), serum C-reactive protein (135.4 mg/liter; upper limit of normal, 8 mg/liter), and Westergren sedimentation rate (92 mm/h; upper limit of normal, 20 mm/h). A decreased serum albumin level (2.8 g/dl; lower limit of normal, 3.2 g/dl) was also documented. Two sets of blood cultures yielded no growth. Due to leukocyte esterase and microscopic leukocyte (5 to 10 per high-power field) findings from a urinalysis, diagnosis of a urinary tract infection was entertained, but culture was not pursued. The patient was treated with empirical vancomycin at 1,250 mg administered intravenously (i.v.) every 12 h (q12h) and levofloxacin at 750 mg i.v. q48h and subsequently discharged.During the hospitalization, the physical finding of an approximately 4-cm-diameter soft granulomatous mass on the hard palate of the posterior pharynx with mild anterior cervical lymphadenopathy prompted outpatient follow-up. An initial maxillofacial computed-tomography (CT) scan exhibited findings most consistent with chronic parasinusitis with extensive opacification of the ethmoid and sphenoid sinuses. Chest radiology was noncontributory. Follow-up maxillofacial radiology revealed a malignantappearing soft-tissu...

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“…Thomas et al 18 reported a case of a 79-year-old diabetic woman presenting with a 4-cm-diameter soft granulomatous mass on the hard palate, which was later diagnosed to be blastomycosis.…”

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