Reconstruction of full width, full thickness cicatricial eyelid defect after eyelid blastomycosis using a modified tarsoconjunctival flap advancement.

Following effective treatment with systemic antifungal therapy, eyelid lesions from blastomycosis infection may be replaced by disfiguring fibrosis and scarring, which may be surgically challenging to correct. A 68-year-old man with biopsy-proven eyelid blastomycosis was treated with 6 months of oral voriconazole, but resolution of the lesion was complicated by cicatricial changes causing complete lower eyelid defect, epicanthal web, cicatricial mechanical ptosis, and skin plaques. Although repair adhered to the fundamentals of eyelid reconstruction, cicatricial changes associated with blastomycosis infection necessitated a modified approach and attachment sites. A tarsoconjunctival flap (Hughes flap) with modified flap connections utilizing cicatrix and remaining viable tissue was employed to reconstruct the lower eyelid defect and combined with tissue advancement using a Mustardé four-flap epicanthoplasty and post-auricular full-thickness skin graft. Satisfactory cosmetic outcome was achieved at last follow-up of 3.5 months postoperatively. This case demonstrates a feasible technique for reconstruction of significant eyelid defects following robust cicatricial changes such as those after blastomycosis. This report also presents the first description of reconstruction of lower eyelid defect and of posterior lamellar loss after blastomycosis infection.

Reconstruction Following Talectomy Due to Disseminated Blastomycosis in Immunocompetent Adult Utilizing Total Talus Prosthesis: A Case Report.

Blastomycosis is a rare condition affecting specific endemic areas in North America. Blastomycosis is characterized primarily as a pulmonary disease but can disseminate to affect other organ systems. Osteomyelitis due to disseminated blastomycosis is a rare condition with limited functional reconstructive options in a young adult. We present a rare case with prolonged antifungal therapy and staged reconstruction with a total talus prosthesis.

Blastomycosis in Children: An Analysis of Clinical, Epidemiologic, and Genetic Features.

BACKGROUND: Blastomyces spp. are endemic in regions of the United States and result in blastomycosis, a serious and potentially fatal infection. Little is known about the presentation, clinic course, epidemiology, and genetics of blastomycosis in children. METHODS: A retrospective review of children with blastomycosis confirmed by culture or cytopathology between 1999 and 2014 was completed. Blastomyces sp. isolates were genotyped by using microsatellite typing, and species were typed by sequencing of internal transcribed spacer 2 (its2). RESULTS: Of the 114 children with blastomycosis identified, 79% had isolated pulmonary involvement and 21% had extrapulmonary disease. There were more systemic findings, including fever (P = .01), poor intake (P = .01), elevated white blood cell count (P < .01), and elevated C-reactive protein level (P < .01), in children with isolated pulmonary disease than in children with extrapulmonary disease. Children with extrapulmonary disease had more surgeries (P = .01) and delays in diagnosis (P < .01) than those with isolated pulmonary infection. Of 52 samples genotyped, 48 (92%) were Blastomyces gilchristii and 4 (8%) were Blastomyces dermatitidis. CONCLUSION: This is the first large-scale study of the clinical, epidemiologic, and genetic features of blastomycosis in children. The majority of the children had isolated pulmonary disease with systemic findings. Patients with extrapulmonary disease were less likely to have systemic symptoms or additional laboratory evidence of infection, which made delays in diagnosis more common. More than 90% of the pediatric cases were caused by B gilchristii.

Blastomyces Tenosynovitis of the Foot and Ankle: A Case Report and Review of the Literature.

Deep fungal infection localized to the foot is not common, and when it occurs it often affects immunocompromised individuals. In this report, we describe the case of an adult diabetic patient who suffered with with Blastomycosis infection of the flexor digitorum longus and peroneal tendon sheaths. The condition was treated with systemic antifungal therapy and surgical debridement.

Blastomycosis infection of the knee treated with staged total knee arthroplasty.

Blastomycosis is a rare fungal disease that can cause intraarticular infection and joint destruction requiring surgical reconstruction. We describe a patient who presented with destruction of the knee joint of unknown etiology. The patient was initially treated with debridement and spacer placement followed by antifungal therapy after cultures grew blastomycosis. Following adequate treatment of the infection, the patient was taken back to the operating room for reconstruction with a total knee arthroplasty. The patient had a successful outcome with no evidence of infection at two years following surgery. To our knowledge, this case report represents the first documented case in which a blastomycotic infection of a native knee was successfully treated with a two-stage total knee arthroplasty.

Surgery for blastomycosis of the spine.

Blastomycosis is a rare fungal infection that primarily produces acute lung infections but may disseminate to multiple sites, including the spine. Once vertebral involvement occurs, an untreated infection may result in vertebral body destruction and paraspinal and epidural abscess formation followed by neurologic injury and loss of structural integrity of the spine. We report the case of a 30-year-old man who had pulmonary blastomycosis (treated with oral itraconazole for 6 months) and presented with a 2-month history of mild thoracolumbar back pain and numbness and tingling in the lower extremities, but no neurologic deficits. Imaging revealed a destructive lesion of T11 with an extensive paravertebral and retropleural abscess tracking a spinal level above and below with extension into the spinal canal. The patient underwent incision and drainage, culture procurement and corpectomy of T11 with autogenous rib graft in a titanium cage, and, 1 week later, posterior fusion and instrumentation. Cultures were positive for Blastomycosis dermatitidis. Oral itraconazole was continued. Blastomycosis that disseminates to the spine may cause serious neurologic and structural complications. In most cases, long-term use of antifungal medication eradicates the infection. Should medical treatment fail, however, surgery is a useful option.

Intracranial blastomycosis presenting as an enhancing cerebellopontine mass.

Isolated Blastomyces dermatitidis infection of the central nervous system is an uncommonly encountered entity. If left untreated it can be fatal; thus accurate diagnosis in a timely manner is critical. A 37-year-old white male presented with a severe headache. An MRI scan revealed a right-sided enhancing cerebellopontine angle mass with extension into the internal acoustic canal and diffuse basilar enhancement. After thorough assessment of the patient, an open surgical biopsy of the lesion was performed for pathological evaluation. The biopsy demonstrated broad-based budding yeasts. The cerebrospinal fluid antigen enzyme immunoassay (EIA) (MVista®) for Blastomyces dermatitidis was also positive with a level of 4.28 EIA units.

Surgery for other pulmonary fungal infections, Actinomyces, and Nocardia.

Surgical participation in the management of fungal infections has changed since the advent of effective antimicrobials. Even so, a surgeon may be called on for a variety of reasons, depending on the specific fungal infection and the evolution of thoracic disease. Specific fungal infections are enumerated. Each organism, its clinical picture, and method of diagnosis are briefly described and the medical and surgical management of thoracic disease are discussed.

Retroperitoneal pyogranulomatous and fibrosing inflammation secondary to fungal infections in two dogs.

CASE DESCRIPTIONS: A 4-year-old spayed female Golden Retriever (dog 1) was examined because of acute edema and erythema in the left hind limb and an inguinal mass, and a 5-year-old female Jack Russell Terrier (dog 2) was examined because of a recurring retro-peritoneal mass. CLINICAL FINDINGS: Dog 1 had an edematous, hyperemic left hind limb with a fixed inguinal mass. Monocytic neutrophilic leukocytosis and hypoalbuminemia were detected. Diagnostic imaging revealed abnormal tissue surrounding the larger vessels and ureters and complete occlusion of the left limb veins. Surgery resulted in incomplete removal of the mass. Histologic examination revealed fibrosing pyogranulomatous inflammation. Results of a Histoplasma antigen test were positive, and reanalysis of the tissues revealed yeast cells indicative of Histoplasma capsulatum. Dog 2 had incomplete removal of a retroperitoneal mass. Histologic examination revealed fibrosing pyogranulomatous inflammation. The mass recurred 8 months later in dog 2; exploratory abdominal surgery at that time resulted in substantial hemorrhage from the adhered caudal aorta. Histologic examination of tissue sections from the second surgery revealed yeast cells consistent with Blastomyces dermatitidis. TREATMENT AND OUTCOME: Both dogs had temporary improvement after surgery. Full clinical resolution required treatment for fungal disease. Dog 1 was treated with itraconazole, then fluconazole (total treatment time, 23 weeks). Dog 2 was treated with fluconazole for 36 weeks. CLINICAL RELEVANCE: Retroperitoneal pyogranulomatous fibrosis caused by fungal infections has not been reported in veterinary medicine. There was substantial morbidity, but the prognosis can be good when this abnormality is recognized and antifungal medications are administered.

Blastomycosis: Case report of an isolated lesion in the distal fibula.

Blastomycosis (Blastomyces dermatitidis) is a fungal infection that occurs primarily in the lungs, but 15% to 60% of patients with systemic blastomycosis have skeletal involvement. Because the symptoms and radiographic appearance of bony lesions are variable, diagnosis and treatment may be delayed if fungal infections are not included in the differential diagnosis for a patient with a lytic bone lesion. We present the case of a man in his late 30s with no local or systemic signs of infection in whom biopsy-curettage of a painful ankle lesion identified budding yeast consistent with North American blastomycosis. After treatment with itraconazole, the patient was symptom-free and had returned to his previous activities without pain or difficulty.

Primary blastomycosis of oral cavity.

BACKGROUND: Blastomycosis is an uncommon male-predominant disease caused by the fungus Blastomyces dermatitidis. The lungs are most commonly affected, and other organs are usually involved by dissemination. Clinical feature and pathohistologic findings are similar to the appearance of squamous cell carcinoma. METHODS AND RESULTS: A 52-year-old male patient who has lived as a farmer on the countryside in Argentina for 35 years presented with an initial histopathologic diagnosis of a squamous cell carcinoma of the right lower jaw. There was no history of pulmonary disease, in particular fever, coughing, or hemoptysis. Final pathohistologic evaluation after resection revealed B. dermatitidis infection. This article presents the first described case of oral manifestation of B. dermatitidis infection in Switzerland. CONCLUSIONS: Manifestation of blastomycosis in oral tissue can mimic the feature of a squamous cell carcinoma and can therefore be a diagnostic pitfall that head and neck surgeons and a pathologist should be aware of.

Patellar blastomycosis in a dog.

A 4-year-old, spayed female, mixed-breed dog was presented for evaluation of chronic left hind-limb lameness. Lytic lesions were observed in the left patella on radiographs of the stifle. A biopsy of the patella led to a histopathological diagnosis of blastomycosis. Surgical debridement followed by a 90-day course of itraconazole and physical rehabilitation resolved the clinical signs and stopped the progression of radiographic lesions. Blastomycosis should be considered as a differential diagnosis for stifle joint lameness with lytic lesions in the patella.

Cerebral Blastomyces dermatitidis infection in a cat.

CASE DESCRIPTION: An 8-year-old domestic shorthair cat was evaluated because of signs of depression, circling, and visual deficits. CLINICAL FINDINGS: The cat had no cutaneous lesions, and results of an ophthalmologic examination and thoracic radiography were within reference limits. Computed tomography of the brain revealed a mass lesion involving the right parietal, temporal, and occipital lobes; the mass was in broad-based contact with the skull and smoothly marginated and had strong homogenous enhancement after contrast agent administration. During craniectomy, samples of the mass were collected for cytologic and histopathologic evaluations and microbial culture. A diagnosis of Blastomyces dermatitidis-associated meningoencephalitis with secondary pyogranulomatous inflammation was made. TREATMENT AND OUTCOME: Amphotericin B (0.25 mg/kg [0.11 mg/lb], IV) was administered on alternate days (cumulative dose, 1.75 mg/kg [0.8 mg/lb]). To minimize the risk of nephrotoxicosis, assessments of serum biochemical variables (urea nitrogen and creatinine concentrations) and urinalyses were performed at intervals. The third dose of amphotericin B was postponed 48 hours because the cat became azotemic. The cat subsequently received fluconazole (10 mg/kg [4.5 mg/lb], PO, q 12 h) for 5.5 months. Six months after discontinuation of that treatment, the cat appeared healthy and had no signs of relapse. CLINICAL RELEVANCE: Brain infection with B dermatitidis is typically associated with widespread disseminated disease. The cat of this report had no evidence of systemic disease. Blastomycosis of the CNS should be considered as a differential diagnosis for brain lesions in cats from areas in which B dermatitidis is endemic.

Blastomycosis: contributions of morphology to diagnosis: a surgical pathology, cytopathology, and autopsy pathology study.

Blastomycosis is caused by the inhalation of spores of the dimorphic fungus, Blastomyces dermatitidis. The reporting of this disease is not required by all states. The diagnosis is established by culture or by identification of broad budding yeast forms in tissue or cytology samples. A retrospective review of blastomycosis was conducted using surgical pathology and cytopathology records of a large community based general hospital, for the years 1982 to 2002; the autopsy records of a university referral center were searched for the years 1992 to 2004. Thirteen surgical/cytology cases were retrieved: 8 localized to the lung (group 1) and 5 with extrapulmonary presentation (group 2). Three of the former were clinically thought to be tumors. Broad-based budding yeast forms with thick cell walls were seen in all but 1 case and identified on conventional routinely stained preparations. Microbiologic culture was positive in 2 lung cases only, in 1 of which it was the sole means of diagnosis. Culture was negative for Blastomyces in the only extrapulmonary case for which a specimen was submitted. One patient in group 2 died, but had a coexistent disseminated gastric adenocarcinoma. No autopsy was performed. Three autopsies of blastomycosis were recovered (group 3). Two patients were on corticosteroids and 1 was diabetic. Premortem diagnoses were established only within a few days of death in 2 patients. Blastomycosis is seldom a fatal disease. Most patients are immune competent; immune compromise favors an aggressive course. Microbiologic culture and conventional morphologic assessment of routine samples have redundant utility in diagnosis.