Transcript Rippon JW. Medical Mycology: The Pathogenic Fungi and

51 y.o. Man with Bilateral
Osteomyelitis of the Hands
David Feldstein, MD
PCC 5/10/06
Patient

51 y.o. man with hx of pulmonary
sarcoidosis
– Osteomyelitis of bilateral 5th fingers

8 weeks (PTA)
– Pain, erythema, swelling right 5th PIP joint
– No trauma, injury, fevers chills
– Urgent care – clinical dx fracture and
splinted
Patient

7 weeks (PTA)
– Return UC increased swelling and pain
– Xray with bony destruction head of 5th
proximal phalynx
– Ceftri x 1 and started on cephalexin

4 weeks (PTA)
– Admitted to outside hospital
– Progression of sx right 5th finger
– Left 5th finger now with swelling and
erythema
Patient

Outside Hospital
– Xray
»Almost complete destruction right 5th
middle phalynx
»Lucency left 5th proximal phalynx
– Bone scan
»Increased signal bilateral 5th fingers and
right wrist
Patient

Outside Hospital Management
– Incision and drainage right 5th finger
– Pin placed for stabilization
– Gram stain and cx of fluid negative
– Vancomycin /Rifampin and discharged
No clinical improvement and worsening
xrays 3 weeks later
 Sent to UW (FINALLY!!)

Why?

Why did he fail treatment?
At UW
No constitutional sx or other skin
findings
 PMH – Sarcoidosis
 SH – Machinist, lives on a farm
 PE

– VSS, NAD
– Lungs clear
– Skin – see photos
Objectives
Recognize improper treatment of
osteomyelitis
 Describe symptoms of blastomycosis
infection
 Describe treatment of blastomycosis

Blastomyces Dermatitidis
Dimorphic fungus
 Mycelial phase in nature
 Converts to yeast at body temperature
 Warm moist soil in wooded areas rich in
organic debris
 Endemic – See figure

Incidence of Blastomycosis in North America
Rippon JW. Medical Mycology: The Pathogenic Fungi and Pathogenic Actinomycetes. 3rd ed.
Philadelphia: WB Saunders; 1988:474.
Clinical Manifestations
Very variable
 Infection caused by inhalation in almost
all cases
 Most cases include symptomatic
pulmonary infection

Wisconsin

2 retrospective studies
– Centers for Disease Control and
Prevention (CDC). Blastomycosis-Wisconsin, 1986-1995. (1996)
– Baumgardner DJ. Halsmer SE. Egan G.
Symptoms of pulmonary blastomycosis:
northern Wisconsin, United States. (2004)
CDC

All reported cases in WI 1986-1995
– 670 cases
– 29 fatal

Primary pulmonary disease without
extrapulmonary manifestations
– 76%

Extrapulmonary disease only
– 18%

Pulmonary and Extrapulmonary
– 6%
Baumgardner

Retrospective investigation of 170
reported cases in Vilas County
– 1979-2001
– 91% pulmonary symptoms

Pulmonary cases contacted and
interviewed (118 of 154)
Patients with Pulmonary Blasto
Cough
90%
Fever
75%
Night Sweats
68%
Weight Loss
68%
Chest Pain
63%
Dyspnea
54%
Myalgias
50%
Hemoptysis
18%
Baumgardner, etal.
Common Extrapulmonary Sx

Skin
– Verrucous or ulcerative

Bone
– Any bone
– Xrays not specific

GU
– Prostatitis and epididymoorchitis

CNS
– Epidural or cranial abscesses
Diagnosis

Diagnosis
– Histology
– Culture
»Easy to culture

Serology
– Not sensitive or specific
– 95% cross reactivity with Histo
– Also cross-reactive with
paracoccidiodomycosis
Treatment
No good RCTs
 Guidelines based on small open label
studies, case series and expert opinion
 Ampho for life threatening
 Itraconazole for mild to moderate
 At least 6 months

IDSA Guidelines
Pulmonary
– Life threatening – Amphotericin B
– Mild/Mod – Itraconazole
Disseminated
 CNS – Ampho B
 Non-CNS
– Life threatening – Ampho B
– Mild/Mod - Itraconazole
Clinical Follow-up
Conclusions

Treatment of osteomyelitis
– Bone Culture
– Reassess when not responding

Manifestations of Blasto
– Pulmonary most common
– Can affect almost any organ

Treatment
– Ampho or Itraconazole
– No good trials of efficacy
References

Centers for Disease Control and Prevention (CDC).
Blastomycosis--Wisconsin, 1986-1995. MMWR - Morbidity &
Mortality Weekly Report. 45(28):601-3, 1996 Jul 19.

Baumgardner DJ. Halsmer SE. Egan G. Symptoms of
pulmonary blastomycosis: northern Wisconsin, United States.
Wilderness & Environmental Medicine. 15(4):250-6, 2004.

Chapman SW. Bradsher RW Jr. Campbell GD Jr. Pappas PG.
Kauffman CA. Practice guidelines for the management of
patients with blastomycosis. Infectious Diseases Society of
America. Clinical Infectious Diseases. 30(4):679-83, 2000 Apr.