The patient is a 45-year-old uninsured day laborer in a remote area of Southern California. He has a slowly growing tumor of his right malar eminence. In our clinics he would have a biopsy and, after that, probably Mohs micrographic surgery. However, that is not this man's reality.
Are there any clinics in California or Arizona that would see such a patient? Your thoughts will be helpful.
Please email David Elpern with suggestions.
Presented by Makayla Powers, PA
History: The patient is a 37 year old man who
presents for an eruption on the right leg. This
developed about 8 months ago as a small area
of erythema. He was initially evaluated in the
ER and was prescribed antibiotics. Since then
he has been on numerous rounds of antibiotics
and he is currently on augmentin. At one point,
his right knee became swollen and he reports
fluid was drained from it in the hospital. The
eruption has continued to spread and has become
painful when palpated. He has been seeing a provider
at the wound care clinic who usually cleans and
dresses the area, however the eruption is not
improving.
Physical exam: On exam, patient has an erythematous
plaque on the right lower leg that measures about
12 cm x 6 cm and is located just below the knee.
There are a few areas that are weeping a yellow fluid.
A bacterial culture and biopsy was done.
Wound culture showed Coagulase Positive Staph MRSA type.
Pathology.
Photomicrographs courtesy of David Jones, MD. Berkshire Medical Center. Note Reference # 1.
First Biopsy 4.17.23
Repeat Biopsy 4/24/23 shows rare spores consistent with Blastomycosis (PAS stain)
Your thoughts will be appreciated and we will update
this presentation as new findings emerge.
References
1. Blastomycosis in the
Capital District of New York State: A Newly Identified Emerging Endemic Area. Adam
Austin David M Jones et. al. Am J Med. 2021 Feb;134(2):e101-e108. PMID:
33091391
Abstract
Background: The
Centers for Disease Control and Prevention and New York State Department of
Health recently identified the Capital District of New York (CDNY) as an
emerging endemic area for blastomycosis. However, no clinical or
epidemiological description of blastomycosis in the CDNY has been published.
Methods: We
performed a retrospective analysis of blastomycosis cases at Albany Medical
Center (AMC) and Albany Stratton Veterans Affairs Medical Center (VAMC) from
January 1, 2000, through June 1, 2019. Patients were identified via an
institution-approved informatics system at the hospital's microbiology
laboratory.
Results: We
identified 20 patients diagnosed with blastomycosis over the past 2 decades.
There was a nearly 9-fold increase in the annual number of cases in 2016-2019
compared with 2000-2015. The majority of patients resided in the CDNY (90%),
and 65% lived within the Mohawk River valley. Most cases (85%) were assumed to
be malignancies or non-mycotic infections prior to diagnosis, with median time
between presentation and diagnosis of 53 days.
Conclusions: Our data support recent reports
that blastomycosis is an emerging disease in the CDNY. Most patients were misdiagnosed as
malignancy or non-mycotic infection, which led to treatment delays.
2. Ross JJ, et. al.
Blastomycosis in New England: 5 Cases and a Review. Open Forum Infect Dis. 2023
Jan 20;10(1):ofad029 Jan. Free PMCarticl
Abstract
The geographic range
of blastomycosis is thought to include New England, but documentation is
sparse. We report 5 cases of infection with Blastomyces dermatitidis that were
likely acquired in New England between 2011 and 2021. Our experience suggests that
chart coding for the diagnosis of blastomycosis is imprecise and that mandatory
reporting might help resolve uncertainties about the prevalence and extent of
blastomycosis.
3. Elena Gonzalez Caldito, Camila Antia, Vesna Petronic-Rosic. Cutaneous Blastomycosis. JAMA Dermatol. 2022 Sep 1;158(9):1064.
