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Blastomycosis: A Review of Mycological and Clinical Aspects. J Fungi (Basel) 2023; 9:jof9010117. [PMID: 36675937 PMCID: PMC9863754 DOI: 10.3390/jof9010117] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Blastomycosis is caused by a thermally dimorphic fungus that thrives in moist acidic soil. Blastomyces dermatitidis is the species responsible for most infections in North America and is especially common in areas around the Great Lakes, the St. Lawrence Seaway, and in several south-central and southeastern United States. Other Blastomyces species have more recently been discovered to cause disease in distinct geographic regions around the world. Infection almost always occurs following inhalation of conidia produced in the mold phase. Acute pulmonary infection ranges from asymptomatic to typical community-acquired pneumonia; more chronic forms of pulmonary infection can present as mass-like lesions or cavitary pneumonia. Infrequently, pulmonary infection can progress to acute respiratory distress syndrome that is associated with a high mortality rate. After initial pulmonary infection, hematogenous dissemination of the yeast form of Blastomyces is common. Most often this is manifested by cutaneous lesions, but osteoarticular, genitourinary, and central nervous system (CNS) involvement also occurs. The diagnosis of blastomycosis can be made by growth of the mold phase of Blastomyces spp. in culture or by histopathological identification of the distinctive features of the yeast form in tissues. Detection of cell wall antigens of Blastomyces in urine or serum provides a rapid method for a probable diagnosis of blastomycosis, but cross-reactivity with other endemic mycoses commonly occurs. Treatment of severe pulmonary or disseminated blastomycosis and CNS blastomycosis initially is with a lipid formulation of amphotericin B. After improvement, therapy can be changed to an oral azole, almost always itraconazole. With mild to moderate pulmonary or disseminated blastomycosis, oral itraconazole treatment is recommended.
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Servais R, Ammar MA, Gurnani PK. Treatment of pulmonary blastomycosis with high-dose liposomal amphotericin B in a patient receiving extracorporeal membrane oxygenation. BMJ Case Rep 2019; 12:12/6/e229612. [PMID: 31253662 DOI: 10.1136/bcr-2019-229612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Blastomycosis-associated acute respiratory distress syndrome (ARDS) has a rare incidence. We report the case of a 29-year-old man with blastomycosis-associated ARDS receiving extracorporeal membrane oxygenation and managed with high-dose liposomal amphotericin B. This case illustrates the importance of timely diagnosis of pulmonary blastomycosis and appropriate dosing of antifungal therapy.
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Affiliation(s)
- Ryan Servais
- Department of Pharmacy, Aurora Saint Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Mahmoud A Ammar
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Payal K Gurnani
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois, USA
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Al-Fares A, Fan E, Husain S, Di Nardo M, Cypel M, Keshavjee S, Herridge MS, Del Sorbo L. Veno-venous extracorporeal life support for blastomycosis-associated acute respiratory distress syndrome. Perfusion 2019; 34:660-670. [PMID: 31027465 DOI: 10.1177/0267659119844391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Blastomyces is a dimorphic fungus endemic to regions of North America, which can lead to pneumonia and fatal severe acute respiratory diseases syndrome in up to 89% of patients. Extracorporeal life support can provide adequate oxygenation while allowing the lungs to rest and heal, which might be an ideal therapy in this patient group, although long-term clinical and radiological outcomes are not known. CLINICAL FEATURES We report on five consecutive patients admitted to Toronto General Hospital intensive care unit between January 2012 and September 2016, with progressive respiratory failure requiring veno-venous extracorporeal life support within 24-96 hours following mechanical ventilation. Ultra-lung protective mechanical ventilation was achieved within 24 hours. Recovery was the initial goal in all patients. Extracorporeal life support was provided for a prolonged period (up to 49 days), and four patients were successfully discharged from the intensive care unit. Long-term radiological assessment in three patients showed major improvement within 2 years of follow-up with some persistent disease-related changes (bronchiectasis, fibrosis, and cystic changes). In two patients, long-term functional and neuropsychological outcomes showed similar limitations to what is seen in acute respiratory distress syndrome patients who are not supported with extracorporeal life support and in acute respiratory distress syndrome patients without blastomycosis, but worse pulmonary function outcomes in the form of obstructive and restrictive changes that correlated with the radiological imaging. CONCLUSION Veno-venous extracorporeal life support can effectively provide prolonged support for patients with blastomycosis-associated acute respiratory distress syndrome that is safe and associated with favorable long-term outcomes.
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Affiliation(s)
- Abdulrahman Al-Fares
- Adult Critical Care Medicine Fellowship Program, University of Toronto, Toronto, ON, Canada.,Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait.,Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
| | - Shahid Husain
- Division of Infectious Diseases and Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Matteo Di Nardo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Pediatric Critical Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Marcelo Cypel
- Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada.,Division of Thoracic Surgery and Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada.,Division of Thoracic Surgery and Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada
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Blastomycosis in Mammals. EMERGING AND EPIZOOTIC FUNGAL INFECTIONS IN ANIMALS 2018. [PMCID: PMC7122209 DOI: 10.1007/978-3-319-72093-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Blastomycosis is a serious fungal disease of dogs, humans, and occasionally other mammals caused by geographically restricted, thermally dimorphic Blastomyces species. Blastomycosis is primarily a canine disease, with approximately ten dogs diagnosed for every human case. Dogs also develop disease more rapidly, thus becoming sentinels for possible human disease. Human and canine blastomycosis may differ according to epidemiology/epizoology, clinical features, performance and use of diagnostics, and management.
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Kauffman CA. Treatment of the Midwestern Endemic Mycoses, Blastomycosis and Histoplasmosis. CURRENT FUNGAL INFECTION REPORTS 2017. [DOI: 10.1007/s12281-017-0281-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Wanta BT, Tyner HL, Bohman JK, Baddour LM. Successful Treatment of Refractory Hypoxemia Secondary to Disseminated Histoplasmosis Using Extracorporeal Membrane Oxygenation Support. ACTA ACUST UNITED AC 2017; 7:161-164. [PMID: 27258180 DOI: 10.1213/xaa.0000000000000374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Refractory hypoxemia secondary to acute respiratory distress syndrome (ARDS) is associated with high mortality. Extracorporeal membraneoxygenation (ECMO) is an accepted strategy for treating refractory hypoxemia in patients with ARDS but is relatively contraindicated in the setting of systemic infections. We present a case of successful ECMO use in a host with refractory hypoxemia secondary to disseminated histoplasmosis with fungemia and discuss our management approach to this difficult patient.
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Affiliation(s)
- Brendan T Wanta
- From the *Division of Anesthesia and Critical Care Medicine, Department of Anesthesiology, †Division of Infectious Diseases, Department of Medicine, and ‡Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Schwartz IS, Embil JM, Sharma A, Goulet S, Light RB. Management and Outcomes of Acute Respiratory Distress Syndrome Caused by Blastomycosis: A Retrospective Case Series. Medicine (Baltimore) 2016; 95:e3538. [PMID: 27149459 PMCID: PMC4863776 DOI: 10.1097/md.0000000000003538] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is an uncommon, highly fatal, and poorly understood manifestation of blastomycosis. Optimal management remains unknown, including the roles of adjunctive corticosteroids and extracorporeal membrane oxygenation (ECMO).We conducted a retrospective chart review of patients with ARDS caused by blastomycosis, managed in intensive care units in Manitoba, Canada, from 1992 to 2014. ARDS was defined using the Berlin definition. Corticosteroid therapy was defined as ≥150 mg cortisol equivalent in 24 hours. Logistic regression was used to identify determinants of a fatal outcome, and bootstrap resampling was used to assess sample size requirements.Forty-three patients with ARDS caused by blastomycosis were identified. ARDS was mild, moderate, and severe in 2 (5%), 12 (28%), and 29 (67%) patients, respectively. Management included amphotericin B (n = 42, 98%), vasopressors (n = 36, 84%), corticosteroids (n = 22, 51%), renal replacement (n = 13, 30%), and ECMO (n = 4, 11%). Seventeen patients (40%) died. All patients treated with ECMO survived (P = 0.14). Corticosteroids were not associated with survival benefit in univariate (P = 0.43) or multivariate analyses (odds ratio 0.52, 95% confidence interval 0.11-2.34). Bootstrap studies indicated that almost 500 patients would be needed to confirm a significant reduction in mortality from corticosteroids (type I error = 0.05, power = 80%).Blastomycosis is an uncommon, albeit important, cause of ARDS in this geographic area. Given the rarity of disease and the large cohort needed to demonstrate mortality benefit, the role of adjunctive therapies, including corticosteroids and ECMO, may remain unconfirmed, and clinical judgment should guide management decisions.
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Affiliation(s)
- Ilan S Schwartz
- From the Department of Medical Microbiology (ISS, JME, RBL); Department of Medicine (ISS, JME, RBL), Section of Infectious Diseases, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Epidemiology and Social Medicine (ISS), Faculty of Health Sciences, University of Antwerp, Antwerp, Belgium; Biostatistical Consulting Unit (AS), George and Fay Yee Center for Healthcare Innovation, University of Manitoba; Department of Pediatrics and Child Health (AS), Section of Nephrology; Department of Medicine (SG), Section of General Internal Medicine; and Department of Medicine (RBL), Section of Critical Care Medicine, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Abstract
Blastomycosis is an endemic fungal infection due to Blastomyces dermatitidis that most commonly causes pneumonia; but the organism can disseminate to any organ system, most commonly the skin, bones/joints, and genitourinary tract. Both immunocompetent and immunocompromised persons can be infected, but more severe disease occurs in the immunocompromised. Blastomycosis can be diagnosed by culture, direct visualization of the yeast in affected tissue, and/or antigen testing. Treatment course and duration depend on severity of illness. For mild to moderate pulmonary disease the treatment is itraconazole. For severe blastomycosis, lipid formulation amphotericin B is given, followed by step-down therapy with itraconazole.
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Affiliation(s)
- Caroline G Castillo
- Division of Infectious Diseases, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI 48109, USA
| | - Carol A Kauffman
- Division of Infectious Diseases, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI 48109, USA; Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Marisa H Miceli
- Division of Infectious Diseases, University of Michigan Health System, 3119 Taubman Center, Ann Arbor, MI 48109, USA.
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Bednarczyk JM, Kethireddy S, White CW, Freed DH, Singal RK, Bell D, Ahmed SZ, Kumar A, Light B. Extracorporeal membrane oxygenation for blastomycosis-related acute respiratory distress syndrome: a case series. Can J Anaesth 2015; 62:807-15. [PMID: 25851019 PMCID: PMC7100112 DOI: 10.1007/s12630-015-0378-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 04/01/2015] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Blastomyces dermatitidis is a dimorphic fungus endemic to North America capable of causing fatal respiratory failure. Acute respiratory distress syndrome (ARDS) complicates up to 10% of pulmonary blastomycosis in hospitalized patients and carries a mortality of 50-90%. This report describes the clinical course of four consecutive patients with blastomycosis-related ARDS treated with venovenous extracorporeal membrane oxygenation (ECMO) during 2009-2014. CLINICAL FEATURES Four adults were referred from northwestern Ontario, Canada with progressive respiratory illnesses. All patients developed diffuse bilateral opacities on chest radiography and required mechanical ventilation within 6-72 hr. Patients satisfied Berlin criteria for severe ARDS with trough PaO2/F i O2 ratios of 44-61 on positive end-expiratory pressure of 12-24 cm H2O. Wet mount microscopy from respiratory samples showed broad-based yeast consistent with B.dermatitidis. Despite lung protective ventilation strategies with maximal F i O2 (patients A-D), neuromuscular blockade (patients A-D), inhaled nitric oxide (patients A and D), and prone positioning (patient D), progressive hypoxemia resulted in initiation of venovenous ECMO by hours 24-90 of mechanical ventilation with subsequent de-escalation of ventilatory support. In all four cases, ECMO decannulation was performed (7-23 days), mechanical ventilation was withdrawn (18-52 days), and the patients survived to hospital discharge (31-87 days). CONCLUSION This report describes the successful application of ECMO as rescue therapy in aid of four patients with refractory blastomycosis-associated ARDS. In addition to early appropriate antimicrobial therapy, transfer to an institution experienced with ECMO should be considered when caring for patients from endemic areas with rapidly progressive respiratory failure.
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Affiliation(s)
- Joseph M Bednarczyk
- Department of Internal Medicine, Section of Critical Care, Health Sciences Centre, University of Manitoba, Room GC425, 820 Sherbrook St., Winnipeg, MB, R3T 2N2, Canada,
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Liebenstein T, Smith JA. Current and future therapeutic strategies for treatment of blastomycosis. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.887465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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