Acute pulmonary blastomycosis - Clinicals, Diagnosis, and Management

Infectious diseases

Clinicals - History

Fact Explanation
History of residing in or travelling to an endemic area Blastomycosis is a common zoonotic fungal infection in endemic areas, like border of the Great Lakes, St. Lawrence River, the Mississippi River and Ohio River. Human infection is common in those areas, and occurs when airborne conidia are inhaled from the soil. If the contacted person's immunity fights against the fungus, it can be contained, but if not, the dimorphic fungus develops into the yeast form and the yeast forms migrate to other sites through blood and lymphatic system. Lungs are the most common initially affected organ. History of residing in or travelling to an endemic area
Blastomycosis is a common zoonotic fungal infection in endemic areas, like border of the Great Lakes, St. Lawrence River, the Mississippi River and Ohio River. Human infection is common in those areas, and occurs when airborne conidia are inhaled from the soil. If the contacted person's immunity fights against the fungus, it can be contained, but if not, the dimorphic fungus develops into the yeast form and the yeast forms migrate to other sites through blood and lymphatic system. Lungs are the most common initially affected organ.
An associated immunodeficiency status. It has been reported that there is a high incidence of blastomycosis in patients who are immunosuppressed, or obese or diabetic. An associated immunodeficiency status.
It has been reported that there is a high incidence of blastomycosis in patients who are immunosuppressed, or obese or diabetic.
Fever, productive cough, shortness of breath and chest pain. The causative yeast Blastomyces dermatitidis initiates an inflammatory reaction in the lungs somewhat similar to bacterial pneumonia in presentation. It may be self-limited , or mimic acute bacterial pneumonia, or even progress to indolent or chronic stages. Pneumonia is the most common manifestation of blastomycosis. The initial response to the yeast is suppurative , hence acute fever, productive cough with purulent sputum and pleuritic type chest pain can be justified. Some cases have been known to mimic bronchogenic carcinoma. Fever, productive cough, shortness of breath and chest pain.
The causative yeast Blastomyces dermatitidis initiates an inflammatory reaction in the lungs somewhat similar to bacterial pneumonia in presentation. It may be self-limited , or mimic acute bacterial pneumonia, or even progress to indolent or chronic stages. Pneumonia is the most common manifestation of blastomycosis. The initial response to the yeast is suppurative , hence acute fever, productive cough with purulent sputum and pleuritic type chest pain can be justified. Some cases have been known to mimic bronchogenic carcinoma.
Rapidly deteriorating shortness of breath Some cases progress to overwhelming blastomycosis and Acute Respiratory Distress Syndrome. Even though the mortality rate can go up as much as 80%, once treated they have a good prognosis. It was uncovered that there was an association between obesity and shorter incubation period with the risk of developing into ARDS. Rapidly deteriorating shortness of breath
Some cases progress to overwhelming blastomycosis and Acute Respiratory Distress Syndrome. Even though the mortality rate can go up as much as 80%, once treated they have a good prognosis. It was uncovered that there was an association between obesity and shorter incubation period with the risk of developing into ARDS.
Other systemic complaints i.e. bone, endocrine glands, skin rashes Due to disseminated blastomycosis. The site it spreads to is unpredictable, and the non-specific symptoms might be the first presentation. There have been various disseminated sited reported throughout the history of research. Other systemic complaints i.e. bone, endocrine glands, skin rashes
Due to disseminated blastomycosis. The site it spreads to is unpredictable, and the non-specific symptoms might be the first presentation. There have been various disseminated sited reported throughout the history of research.
History of maternal blastomycosis in pregnancy Blastomycosis can be transmitted through the placenta, but it happens so not in all cases. The complications of blastomycosis in pregnancy is more to the infant/fetus than the mother. There have been reported stillbirths, disseminated miliary blastomycosis. History of maternal blastomycosis in pregnancy
Blastomycosis can be transmitted through the placenta, but it happens so not in all cases. The complications of blastomycosis in pregnancy is more to the infant/fetus than the mother. There have been reported stillbirths, disseminated miliary blastomycosis.
Asymptomatic Some patients are asymptomatic and the findings are incidental. Asymptomatic
Some patients are asymptomatic and the findings are incidental.

Clinicals - Examination

Fact Explanation
Febrile The inflammatory response to fungal infection. The fever can be high, similar to acute bacterial pneumonia. Febrile
The inflammatory response to fungal infection. The fever can be high, similar to acute bacterial pneumonia.
Evidence of lung consolidation or cavitation Pulmonary blastomycosis can mimic acute bacterial pneumonia, chronic pneumonia, tuberculosis or even bronchial carcinoma, which are more common clinical entities with similar findings. Evidence of lung consolidation or cavitation
Pulmonary blastomycosis can mimic acute bacterial pneumonia, chronic pneumonia, tuberculosis or even bronchial carcinoma, which are more common clinical entities with similar findings.
Tachypnea, cyanosis The infection developing into overwhelming blastomycosis and acute respiratory distress syndrome. Tachypnea, cyanosis
The infection developing into overwhelming blastomycosis and acute respiratory distress syndrome.
Skin rash There have been reported cases of skin rashes associated with pulmonary blastomycosis. Skin rash
There have been reported cases of skin rashes associated with pulmonary blastomycosis.

Investigations - Diagnosis

Fact Explanation
Wet smears for microscopy. Direct examination of respiratory secretions (sputum, tracheal secretions, gastric washings) with potassium hydroxide solution helps visualizing the yeast. It's quicker than culture but not as accurate as it. Wet smears for microscopy.
Direct examination of respiratory secretions (sputum, tracheal secretions, gastric washings) with potassium hydroxide solution helps visualizing the yeast. It's quicker than culture but not as accurate as it.
Sputum culture and miscroscopy The positive yield from the cultures are high and it's the method of definitive diagnosis. But it takes around 5 weeks to get the culture reports. Sputum culture and miscroscopy
The positive yield from the cultures are high and it's the method of definitive diagnosis. But it takes around 5 weeks to get the culture reports.
Chest radiography Radiography is not diagnostic but the extent and severity of blastomycosis pneumonitis can be appreciated. The expected signs are pulmonary infiltrates, the distribution and parenchymal patterns of disease, and the prevalence of lymphadenopathy, pleural effusions, and cavity formations. Chest radiography
Radiography is not diagnostic but the extent and severity of blastomycosis pneumonitis can be appreciated. The expected signs are pulmonary infiltrates, the distribution and parenchymal patterns of disease, and the prevalence of lymphadenopathy, pleural effusions, and cavity formations.
Antigen testing Using immunoassay methods. It has yielded very satisfactory results, and novel ways are still under investigation. Antigen testing
Using immunoassay methods. It has yielded very satisfactory results, and novel ways are still under investigation.

Management - Supportive

Fact Explanation
Notification Blastomycosis usually erupts as epidemics since the yeast coccidia are airborne. It is also an occupational hazard in the health-care personnels and the staff involved in postmortem examinations. It is necessary to report on diagnosis and take necessary public health measures as indicated. Notification
Blastomycosis usually erupts as epidemics since the yeast coccidia are airborne. It is also an occupational hazard in the health-care personnels and the staff involved in postmortem examinations. It is necessary to report on diagnosis and take necessary public health measures as indicated.

Management - Specific

Fact Explanation
Observation The patients who recover spontaneously and asympatomatic patients who may be diagnosed afterwards, require no treatment but need careful observation. Observation
The patients who recover spontaneously and asympatomatic patients who may be diagnosed afterwards, require no treatment but need careful observation.
Antifungals the patients who have symptomatic disease or the immunocompromised, who have a risk for overwhelming infection and ARDS require treatment with anti fungals. The drug of choice for the immunocompromised, in those who have failed to eradicate the infection with conventional antifungals is amphotericin B. Azoles are less effcetive but less toxic. i.e. ketoconazole, itraconazole, and fluconazole. Intravenous antifungals can be used in severe disease. Antifungals
the patients who have symptomatic disease or the immunocompromised, who have a risk for overwhelming infection and ARDS require treatment with anti fungals. The drug of choice for the immunocompromised, in those who have failed to eradicate the infection with conventional antifungals is amphotericin B. Azoles are less effcetive but less toxic. i.e. ketoconazole, itraconazole, and fluconazole. Intravenous antifungals can be used in severe disease.

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