Blastomycosis

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http://cmr.asm.org/content/23/2/367.full.pdf

Blastomycosis

Geoff McKee, MD

Resident Physician

Public Health and Preventive Medicine

University of British Columbia

http://www.metal-archives.com/images/1/2/8/3/128324_logo.jpg?1645

Not just a heavy metal band

...although potentially as hardcore

Acknowledgements

 Dr. Michelle Kates – primary veterinarian

 Dr. Eleni Galenis – Zoonosis Lead, BCCDC

 Dr. Linda Hoang – Medical Microbiologist, BCCDC

 Dr. Mohammed Morshed – Medical Microbiologist, BCCDC

 Dr. Theresa Burns - Public Health Veterinarian (involved in case)

Objectives

Review blastomycosis

Epidemiology

Pathophysiology

Presentation

http://cmr.asm.org/content/23/2/367/F8.expansion.html

Management

Case 1: Canine Blastomycosis Infection

Case 2: Red Panda Blastomycosis Infection (Dr.

Snyman)

Discuss hazards of imported blastomycosis in BC

What is Blastomycosis?

 A systemic pyogranulomatous infection endemic to regions of mid-western and eastern North

America

 Caused by Blastomyces spp.

 First identified by Dr. T. Caspar

Gilchrist, a dermatologist in

Baltimore http://www.photogravure.com/photo gravure_images/large/Ulmann_03_32.j

pg

Geographic Distribution

 Eastern United States

 Central Canada

 Globally

 Southeast Asia

 Africa

 Europe

 Middle East http://img.medscape.com/article/821/652/821652-figure.jpg

Environmental Factors

 Typically exist in mycelial form in environment

 Spores bound tightly to filaments and become unbound in presence of high humidity

 Transmission typically associated with humid environments (Rivers, streams etc) https://www.gov.mb.ca/mit/floodinfo/floodoutlo ok/images/pembina_river_above_lorne_lake.jpg

http://www.cdc.gov/fungal/images/blastomycosislifecycle.jpg

Hosts and Transmission

 Hosts

 Humans

 Dogs, cats, foxes, pandas, lions etc

 Transmission

 Primarily through inhalation of airborne conidia

 Cutaneous infection possible through direct inoculation

 Pathophysiology

 Conversion to yeast form dependant on temperature and nutrients http://www.cdc.gov/fungal/images/blastomycosis-lifecycle.jpg

Clinical Disease

Presentation

 Pulmonary

 Cutaneous

Systemic Illness involving other organs

Treatment

 Mild Disease

 Azoles -> itraconazole etc.

 Moderate to Severe Disease

 Amphoteracin B

Brömel, C., & Sykes, J. E. (2005)

López-Martínez, R., & Méndéz-Tovar, L. J. (2012).

Case 1 – Initial Presentation

 1.5 year old Portuguese Water

Dog presented to vet in

January 2015 for skin lesions on its back.

 Diagnosed with sterile nodular panniculitis on biopsy with negative bacterial cultures

 Treated with steroids

Case 1 – A turn for the worse

 Developed fulminant illness compatible with blastomycosis (fever, respiratory distress, enlarged lymph nodes)

 Lymph node aspirate sent for testing - Blastomyces visualized on microscopy and confirmed via PCR

*Not from actual speciman http://cmr.asm.org/content/23/2/367.full.pdf

Case 1 – Pulmonary Infiltrates

Before Steroids After Steroids

Case 1 – Treatment and Recovery

 The dog was started on

fluconazole and, following an increase in dose, improved dramatically.

 Likely to test urine for Blastomyces antigen prior to halting treatment

Case 1 – Reporting to Public Health

 BCCDC was notified following the diagnosis of blastomycosis

 A repeat lymph node aspirate was obtained by PHSA labs and the diagnosis was confirmed on microscopy. Blastomyces was also cultured from the sample.

Case 1 - Public Health Investigation

Exposure History

 Traveled via car to southwestern Manitoba

6 months prior to the onset of symptoms.

While in Manitoba, the dog swam in a river.

 Travel in BC was also documented with trips to the Interior, Vancouver Island and various locations on the lower mainland.

 Travel to Washington State also documented

 The dog lived in a condo in Vancouver, with no backyard.

http://www.gov.mb.ca/health/rha/m ap.html

Case 1 – Considering the Evidence

 Considering likelihood of exposures:

 Blastomycosis endemic to Manitoba (particularly eastern Manitoba) and likely

Saskatchewan

 No cases of locally acquired blastomycosis reported in British Columbia

 No evidence of local acquisition of blastomycosis in Washington State (although exposure history of several cases unclear as per consultation with WA Public

Health)

Case 1 - Conclusion

Blastomyces likely acquired during trip to Manitoba

 Unable to prove or disprove acquisition in British Columbia

 Further investigation required if subsequent cases arise in BC with uncertain exposure histories

Thank you to Dr. Kates for granting permission to use case photos

References

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