Blastomycosis in Children

Abstract

Infections due to Blastomyces dermatitidis are not commonly encountered in children and adolescents. Knowledge of the diagnosis and treatment of this disease is largely based upon experience with adult patients. We recently reviewed our experience with blastomycosis to evaluate the difficulties in diagnosis and treatment of this disease in the pediatric population. Ten patients with blastomycosis were identified during our review, and five had pulmonary disease alone. Of these five patients, four required open-lung biopsy for diagnosis, even though three had previously undergone bronchoalveolar lavage. The response to treatment with the oral azole antifungal agents (ketoconazole, fluconazole, and itraconazole) was limited, and the agent with the greatest success remains amphotericin B. Until more data are available, amphotericin B should be used for complicated and life-threatening cases of blastomycosis. If oral azole agents are used for non-life-threatening cases, patients should be followed closely, and if clinical deterioration occurs or serum levels of medications are not adequate, then amphotericin B should be substituted for the oral azole agent.

Atypical Cutaneous Blastomycosis in a Child With Juvenile Idiopathic Arthritis on Infliximab

“…10,12 Pediatric cases of any form of blastomycosis are uncommon, comprising 3% to 11% of all infections. 13 Up to 50% of pediatric blastomycosis infections may be asymptomatic. 14,15 A retrospective review of 70 pediatric patients with systemic blastomycosis from Arkansas showed that only 16% of patients exhibited secondary cutaneous findings.…”

“…16 Two subsequent series from the same region examined a total of 20 pediatric patients with blastomycosis infections, 5 of whom presented with secondary cutaneous findings; all patients identified with cutaneous findings also presented with pulmonary disease. 13,16 A separate 30-year retrospective review from Manitoba, Canada, identified 34 pediatric patients with blastomycosis, of whom 18% presented with cutaneous findings. 17 Finally, a more recent 10-year review from Wisconsin identified 17 pediatric cases of blastomycosis; of these, 6 presented with cutaneous findings, 5 of whom had concurrent pulmonary disease.…”

Blastomycotic Multifocal Arthritis and Osteomyelitis in the Urban Setting

“…In children, cases are infrequent, accounting for 3%-10% of total reported cases, with pneumonia being the most common manifestation 7 . Less commonly, blastomycosis has been reported to cause arthritis and/or osteomyelitis in children 8,9 . Blastomycotic arthritis is usually reported as an acute monoarticular arthritis that may be asymptomatic.…”

“…Involvement of multiple joints is very atypical. In children, only 3 reports have documented arthritis as a presenting manifestation of blastomycosis 8,9,10 . Of these, only 1 report discusses a child presenting with arthritis of more than 1 joint 10 .…”

“…On review of the literature, the majority of disseminated cases in children (including bone/joint involvement) received parenteral liposomal amphotericin B at smaller doses of 10 to 35 mg/kg total followed by a 2-6 month course of itraconazole or ketoconazole. However, there have been reports of cases of disease recurrence in children with pulmonary blastomycosis who received < 30 mg/kg parenteral antifungal therapy 9 . Based on literature review and our own case series, the IDSA guidelines regarding dose and length of parenteral antifungal therapy in pulmonary or disseminated blastomycosis are appropriate.…”