Cutaneous, Intranasal Blastomycosis Infection in Two Patients from Southern West Virginia: Diagnostic Dilemma

Abstract

Blastomycosis is a dimorphic fungus caused by the species of Blastomyces dermatitidisand Blastomyces gilchristii, which are endemic to the Ohio River and Mississippi River Valleys. It is commonly found in soil or decomposing wood. It is capable of infecting both immunocompromised and immunocompetent patients via the respiratory tract by inhaling conidia, where it may remain asymptomatic for a prolonged period of time. Extrapulmonary complications can occur in disseminated disease due to haematogenous spread from the lungs to other organ systems. Haematogenous dissemination from the lungs occurs most commonly to the skin. Although rare, primary cutaneous blastomycosis can also occur with direct inoculation through the trauma of the skin. Patients presenting with cutaneous blastomycosis are often misdiagnosed with malignant neoplasms and may not be appropriately managed until further testing and tissue biopsy. Currently, there are only four previous case reports of blastomycosis presenting in the intranasal region. We report two cases of cutaneous blastomycosis of the nasal passages and upper lip with pulmonary manifestations in Southern West Virginia. These patients first presented with cutaneous symptoms, which were originally treated for melanoma and squamous cell carcinoma and were later diagnosed with systemic blastomycosis.

Disseminated Blastomycosis in an Immunocompetent Patient

“…B. dermatitidis is the most common organism in North America responsible for blastomycosis. It usually spreads by inhalation and produces primary lung lesions [ 1 , 2 ]. It can spread through a hematogenous route to other organs such as skin, CNS, and bone [ 3 ].…”

“…Blastomycosis is a fungal infection caused by Blastomyces dermatitidis, a dimorphic fungus endemic in the Ohio and Mississippi River valleys, the Great Lakes region, and the southeastern United States [ 1 ]. Pulmonary infection is the most common presentation following inhalation of the spores, however, Blastomycosis can range from asymptomatic infection to fulminant infection with acute respiratory distress syndrome (ARDS) and death [ 1 , 2 ]. Extrapulmonary disease occurs following hematogenous spread, with the skin being the most common site of extrapulmonary disease [ 1 , 2 ].…”

“…Pulmonary infection is the most common presentation following inhalation of the spores, however, Blastomycosis can range from asymptomatic infection to fulminant infection with acute respiratory distress syndrome (ARDS) and death [ 1 , 2 ]. Extrapulmonary disease occurs following hematogenous spread, with the skin being the most common site of extrapulmonary disease [ 1 , 2 ]. In descending order, skin, bone, prostate, and central nervous system (CNS) involvements are the most reported manifestations of extrapulmonary blastomycosis [ 3 ].…”

Enigmatic Rapidly Enlarging Nasal Mass That Is Not Cancer

“…Blastomycosis can present with a wide range of symptoms, and cutaneous manifestations are common representing 40–80% of the cases subdivided into verrucous and ulcerative forms; cases presenting with facial verrucous plaques have been reported [ 2 , 3 , 7 – 9 ].…”

“…Transmission is through inhalation of aerosolized conidia leading to a wide range of system involvement [1,2]. While a majority of cases present with respiratory problems, there have been quite a few presentations with primary extrapulmonary manifestations causing diagnostic dilemma [3][4][5][6].…”