Mystery Plaque

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)

Enlarge image below and look for the arrow.

Diagnosis:  Cutaneous Blastomycosis. 
We plan to have patient get a CXR,

 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.