12/6/2016 Blastomycosis:FungalInfections:MerckVeterinaryManual

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FungalInfections

Blastomycosis

Blastomycosis, caused by the dimorphic fungus Blastomyces

dermatitidis, is characterized by pyogranulomatous lesions in various
tissues.Itismostcommoninpeople,dogs,andcatsbuthasalsobeen
described in such widely divergent species as horses, ferrets, deer,
wolves, African lions, bottlenosed dolphins, and sea lions. It appears
nottobeadiseaseofcattle,sheep,orpigs.Blastomycosisisgenerally
limited to North America, and most cases have occurred in the
Mississippi,Missouri,Tennessee,andOhioRiverbasinsandalongthe
GreatLakesandtheSt.LawrenceSeaway.Thereisanendemicarea
inthePacificnorthwest.Evenwithintheseriverbasins,theorganismis
found in geographically restricted areas. Beaver dams and other
habitats where soil is moist, acidic, and rich in decaying vegetation
mayserveastheecologicnichefortheorganism,butitisoftendifficult
tofindintheenvironment.Theorganismhasalsobeenrecoveredfrom
pigeon and bat feces. Rain, dew, or fog may play a critical role in
liberatingtheinfectiveconidia,whichthenareaerosolizedandinhaled.
When respiratory defenses are overwhelmed or immunosuppressed,
disseminated disease occurs via hematogenous spread from the
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lungs.Cutaneouslesionsmayresultfromaprimaryentrythroughthe
skin or, more commonly, by dissemination from a pulmonary focus.
Needlestick injuries to veterinary personnel after aspiration of
cutaneous lesions from infected animals have resulted in primary
cutaneousinfection.Ocularlesionstendtodevelopfirstintheposterior
segment, resulting in granulomatous chorioretinitis and retinal
detachment. Anterior segment involvement often follows, resulting in
anterioruveitisandpanophthalmitis.

ClinicalFindings
The signs vary with organ involvement and are Thoracicblastomycosis,
radiograph,dog
not specific. Weight loss may be accompanied
by coughing, anorexia, lymphadenopathy,
dyspnea,oculardisease,lameness,skinlesions,
and fever. Dry, harsh lung sounds from lung
lesionsarecommonindogswithblastomycosis.
Signs of pulmonary involvement are seen in as many as 85% of
affected dogs. Severe pulmonary involvement results in hypoxemia,
whichindicatesapoorprognosis.Lymphnodeinvolvementisseenin
approximately half of affected dogs, which is about the same
proportionofdogsthathavecutaneousinvolvement.Skinlesionsmay
include proliferative granulomas and subcutaneous abscesses that
ulcerateanddrainaserosanguineousdischarge.Theskinlesionsare
often very small and multifocal in dogs, but large abscesses are
occasionally seen, especially in cats. The planum nasale, face, and
nail beds are most often involved. Signs of ocular blastomycosis are
seen in 30%50% of affected dogs and include blindness, uveitis,
glaucoma, and retinal detachment. Lameness associated with fungal
osteomyelitis or severe paronychia occurs in approximately one
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quarterofaffecteddogs.CNSsignsareuncommon,occurringin<5%
of dogs, but they may be more common in cats. The pattern of
systemic involvement is similar in cats, but cats are affected far less
commonly than dogs. Hematuria and dysuria may be seen with
urogenitalblastomycosis.

Lesions:
Gross lesions consist of few to numerous, variablesized, irregular,
firm, gray to yellow areas of pulmonary consolidation and nodules in
the lungs and thoracic lymph nodes. Dissemination may result in
nodular lesions in various organs but especially the skin, eyes, and
bone. Cutaneous lesions are single or multiple papules, or chronic,
draining,nodularpyogranulomas.

Diagnosis
Blastomycosis should be considered in dogs with draining cutaneous
nodules and signs of respiratory disease. In cats, respiratory tract
involvement is seen most frequently, followed by involvement of the
CNS, regional lymph nodes, skin, eyes, and GI and urinary tracts.
Radiographic findings in the lungs include noncalcified nodules or
consolidation,withenlargementofthebronchialandmediastinallymph
nodes.Thepredominantpatternsonthoracicradiographsarethoseof
diffuse nodular interstitial and peribronchial densities. Commonly, the
bronchiallymphnodesaregreatlyenlargedandappearinradiographs
as dense masses. Diagnosis can be made from biopsy of tissue or
aspirated specimens taken from cutaneous lesions or other involved
organsbythepresenceofthickwalledyeastthatoftenhavedaughter
cells budding from a broad base. These round to ovoid, pale pink
(H&E) blastospores measure 825 m and have a refractile, double
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contoured wall. They may be empty or contain basophilic nuclear

material and have single, broadbased buds. An antibody response,
detected by agar gel immunodiffusion, usually occurs, but this
response is neither sensitive nor specific when attempting to make a
definitivediagnosis.AnenzymeimmunoassayforantibodiestorBAD1
repeat has shown improved sensitivity. A recently developed antigen
enzyme immunoassay has been used in both serum and urine to
detect cellwall galactomannan that is immunologically
indistinguishable in histoplasmosis and blastomycosis. Although the
titerisnotusefulindifferentiatingbetweenthetwoinfections,ithelps
diagnosethepresenceofoneofthesetwosystemicmycoses.

Treatment
Itraconazole(5mg/kg/day)isthetreatmentofchoicefordogsandcats
withblastomycosis.Aminimumof2mooftreatmentisnecessary,and
the drug should be continued until active disease is not apparent.
Clinical cure can be expected in ~70% of dogs, with recurrence
monthsoryearsaftertreatmentnotedin~20%oftreateddogs.Most
dogswillrespondtoretreatmentwithitraconazole.Otherazolessuch
asfluconazoleandketoconazolearenotaseffectiveasitraconazole,
but a study evaluating costeffectiveness of fluconazole showed it to
be a less expensive alternative, despite longer treatment times. In
fulminating cases of blastomycosis, especially those with evidence of
hypoxemia,combinationtherapywithamphotericinBanditraconazole
is recommended. Short courses of antiinflammatory dosages of
glucocorticoids have been advocated during the first few days of
treatment by some, but steroid use is controversial and may actually
worsen the prognosis. The prognosis is best for dogs with only mild

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lungdisease,ismoreguardedfordogswithmoderatetoseverelung
disease,andispoorestfordogswithCNSinvolvement.

Lastfullreview/revisionMay2014byJosephTaboada,DVM,DACVIM

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