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.

Keywords: beckley; blastomyces dermatitidis; blastomyces gilchristii; blastomycosis; cutaneous blastomycosis; dimorphic fungus; intranasal blastomycosis; intranasal squamous mucosa biopsy; squamous cell carcinoma; west virginia.

Figure 1. Biopsy of the intranasal squamous mucosa (Hematoxylin and eosin stain) showing acute inflammation and multiple giant cells

Figure 2. Yeast-like organisms with thick refractile wall and broad-based budding (red circle)

Figure 3. Periodic acid-Schiff (PAS) stain showing blastomycosis with characteristic broad-based budding (red circle)

Figure 4. Periodic acid-Schiff (PAS) stain showing one cell in particular and the large based budding as daughter cell is being produced (red circle)

Figure 5. Grocott's methenamine silver (GMS) stain showing budding cells of blastomycosis (red circles)

Figure 6. Post-treatment (after itraconazole and debridement of fungating nasal/upper lip lesion) picture showing cutaneous disseminated blastomycosis on nose

Figure 7. Ulcerating blastomycosis lesion on the right index finger, observed during physical exam

Figure 8. Blastomycosis lesion on left intranasal passageway and middle of upper lip, observed during physical examination