Blastomycosis
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Transcript Blastomycosis
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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
Brömel, C., & Sykes, J. E. (2005)
Presentation
Pulmonary
Cutaneous
Systemic Illness
involving other
organs
Treatment
Mild Disease
Azoles -> itraconazole etc.
Moderate to Severe Disease
Amphoteracin B
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
Baily, G. G., Robertson, V. J., Neill, P., Garrido, P., & Levy, L. F. (1991). Blastomycosis in Africa: Clinical Features, Diagnosis, and Treatment. Clinical Infectious Diseases, 13(5), 1005–1008.
http://doi.org/10.1093/clinids/13.5.1005
Bernstein, S., Brunner, H. I., Summerbell, R., Allen, U., Babyn, P., & Richardson, S. E. (2002). Blastomycosis acquired by three children in Toronto. The Canadian Journal of Infectious Diseases = Journal
Canadien Des Maladies Infectieuses, 13(4), 259–63. Retrieved from /pmc/articles/PMC2094876/?report=abstract
Bialek, R., Ibricevic, A., Fothergill, A., & Begerow, D. (2000). Small Subunit Ribosomal DNA Sequence Shows Paracoccidioides brasiliensis Closely Related to Blastomyces dermatitidis. J. Clin. Microbiol.,
38(9), 3190–3193. Retrieved from http://jcm.asm.org.ezproxy.library.ubc.ca/content/38/9/3190.short
Brömel, C., & Sykes, J. E. (2005). Epidemiology, diagnosis, and treatment of blastomycosis in dogs and cats. Clinical Techniques in Small Animal Practice, 20(4), 233–9.
http://doi.org/10.1053/j.ctsap.2005.07.004
Brown, E. M., McTaggart, L. R., Zhang, S. X., Low, D. E., Stevens, D. A., & Richardson, S. E. (2013). Phylogenetic analysis reveals a cryptic species Blastomyces gilchristii, sp. nov. within the human
pathogenic fungus Blastomyces dermatitidis. PloS One, 8(3), e59237. http://doi.org/10.1371/journal.pone.0059237
Chapman, S. W., Dismukes, W. E., Proia, L. A., Bradsher, R. W., Pappas, P. G., Threlkeld, M. G., & Kauffman, C. A. (2008). Clinical practice guidelines for the management of blastomycosis: 2008
update by the Infectious Diseases Society of America. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 46(12), 1801–12.
http://doi.org/10.1086/588300
Crampton, T. L., Light, R. B., Berg, G. M., Meyers, M. P., Schroeder, G. C., Hershfield, E. S., & Embil, J. M. (2002). Epidemiology and clinical spectrum of blastomycosis diagnosed at Manitoba hospitals.
Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 34(10), 1310–6. http://doi.org/10.1086/340049
Davies, J. L., Epp, T., & Burgess, H. J. (2013). Prevalence and geographic distribution of canine and feline blastomycosis in the Canadian prairies. The Canadian Veterinary Journal. La Revue
Vétérinaire Canadienne, 54(8), 753–60. Retrieved from /pmc/articles/PMC3711163/?report=abstract
Government of Canada, P. H. A. of C. (2011). Blastomyces dermatitidis - Pathogen Safety Data Sheets. Retrieved from http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/blastomyces-dermatitidiseng.php#footnote2
Hannah, E. L., Bailey, A. M., Hajjeh, R., Gershman, K., Lindsley, M., & Hoffman, R. E. (2001). Public health response to 2 clinical cases of blastomycosis in colorado residents. Clinical Infectious Diseases :
An Official Publication of the Infectious Diseases Society of America, 32(11), E151–3. http://doi.org/10.1086/320516
http://doi.org/10.1023/B:MYCO.0000003558.71489.01
References
Hay, R. (2000). Blastomycosis: what’s new? Journal of the European Academy of Dermatology and Venereology, 14(4), 249–250.
http://doi.org/10.1046/j.1468-3083.2000.00098.x
Herrmann, J. A., Kostiuk, S. L., Dworkin, M. S., & Johnson, Y. J. (2011). Temporal and spatial distribution of blastomycosis cases among humans
and dogs in Illinois (2001-2007). Journal of the American Veterinary Medical Association, 239(3), 335–43.
http://doi.org/10.2460/javma.239.3.335
Johnson, L. B., & Kauffman, C. A. (2003). Voriconazole: a new triazole antifungal agent. Clinical Infectious Diseases : An Official Publication
of the Infectious Diseases Society of America, 36(5), 630–7. http://doi.org/10.1086/367933
Klein, B. S., Vergeront, J. M., Disalvo, A. F., Kaufman, L., & Davis, J. P. (2012). Two Outbreaks of Blastomycosis Along Rivers in Wisconsin:
Isolation of Blastomyces dermatitidis from Riverbank Soil and Evidence of its Transmission Along Waterways. American Review of Respiratory
Disease. Retrieved from http://www.atsjournals.org.ezproxy.library.ubc.ca/doi/abs/10.1164/ajrccm/136.6.1333#.VVONPY5VhBc
López-Martínez, R., & Méndéz-Tovar, L. J. (2012). Blastomycosis. Clinics in Dermatology, 30(6), 565–72.
http://doi.org/10.1016/j.clindermatol.2012.01.002
McCullough, M. J., DiSalvo, A. F., Clemons, K. V, Park, P., & Stevens, D. A. (2000). Molecular epidemiology of Blastomyces dermatitidis.
Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 30(2), 328–35.
http://doi.org/10.1086/313649
McDonough, E. S., Wisniewski, T. R., Penn, L. A., Chan, D. M., & McNamara, W. J. (1976). Preliminary studies on conidial liberation of
Blastomyces dermatitidis and Histoplasma capsulatum. Medical Mycology, 14(2), 199–204. http://doi.org/10.1080/00362177685190271
Pfaller, M. A., & Diekema, D. J. (2010). Epidemiology of invasive mycoses in North America. Critical Reviews in Microbiology, 36(1), 1–53.
http://doi.org/10.3109/10408410903241444
Public Health and Primary Health Care Division. (2013). Manitoba Annual Summary of Communicable Diseases. Retrieved from
http://www.gov.mb.ca/health/publichealth/surveillance/cds/docs/2013.pdf
Reed, K. D., Meece, J. K., Archer, J. R., & Peterson, A. T. (2008). Ecologic niche modeling of Blastomyces dermatitidis in Wisconsin. PloS One,
3(4), e2034. http://doi.org/10.1371/journal.pone.0002034
Rodriguez, R. C., Cornock, E., White, V. A., & Dolman, P. J. (2012). Eyelid blastomycosis in British Columbia. Canadian Journal of
Ophthalmology. Journal Canadien D’ophtalmologie, 47(3), e1–2. http://doi.org/10.1016/j.jcjo.2012.03.008
Salas-Alanis, J. C., Martinez, M. F., Garcia-Melendez, M., Gonzalez, B. L., & Ocampo-Candiani, J. (2013). Blastomycosis imported to
Monterrey, Mexico: fifth case reported in Mexico. Mycoses, 56(4), 495–7. http://doi.org/10.1111/myc.12051
Seitz, A. E., Younes, N., Steiner, C. A., & Prevots, D. R. (2014). Incidence and trends of blastomycosis-associated hospitalizations in the United
States. PloS One, 9(8), e105466. http://doi.org/10.1371/journal.pone.0105466
Storms, T. N., Clyde, V. L., Munson, L., & Ramsay, E. C. (2003). BLASTOMYCOSIS IN NONDOMESTIC FELIDS. Journal of Zoo and Wildlife
Medicine, 34(3), 231–238. http://doi.org/10.1638/1042-7260(2003)034[0231:BINF]2.0.CO;2
References
Vasquez, J. E. (1998). Blastomycosis in Northeast Tennessee. CHEST Journal, 114(2), 436. http://doi.org/10.1378/chest.114.2.436
Velázquez, R., Muñoz-Hernández, B., Arenas, R., Taylor, M. L., Hernández-Hernández, F., Manjarrez, M. E., & López-Martínez, R. (2003). An Imported Case of Blastomyces Dermatitidis Infection in Mexico.
Mycopathologia, 156(4), 263–267.