Journal of the Louisiana State Medical Society
A 36-Year-Old Male With a Painless Lower Extremity Skin Lesion
Alireza Hamidian Jahromi, MD, MRCS; Howard W. Wright, MD
CASE REPORT A 36-year-old previously healthy African-American male truck driver presented with a 12-month history of a large (10 x 6 cm) painless, circular, expanding plaque on the posterolateral aspect of his left-lower thigh associated with serous discharge and discomfort (Figure 1). Differ- ent courses of topical and oral antibiotics did not resolve the lesion. The patient did not have chills, fever, cough, sputum, night sweat, or weight loss. Punch biopsy results from four different areas of the plaque were non-diagnostic but showed chronic, nonspecific inflammation and fibrosis. CT scan of the thigh revealed localized superficial irregular nodular soft tissue thickening associated with mild under- lying subcutaneous fat stranding. There was no involve- ment of thigh musculature/bones and no evidence of fluid collections/abscess. HIV serology and TB skin test were negative. The patient had a history of incidental finding of right lung middle lobe infiltrate on a chest X-ray (CXR) without having clinical signs of pneumonia (chills, fever, DISCUSSION Blastomycosis is a fungal infection which is caused by Blastomyces dermatitidis and is especially endemic in areas of the United States with a moist climate, i.e. Loui- siana, Mississippi, Tennessee, Illinois, and Wisconsin. 1 In Louisiana, the highest number of cases has been reported fromWashington, Tangipahoa, Jefferson, and St Tammany Parishes. 2 Although pulmonary disease ranging from sub- clinical asymptomatic infection to acute respiratory distress syndrome (less than 10% of cases) is the most common manifestation, involvement of bone, skin, genitourinary, and central nervous system can be seen. 1,3 Inhalation of aerosolized conidial forms of the organism, hematogenous spread following organism transformation to a yeast after pulmonary infection (thick cell wall in yeast form confers resistance to phagocytosis), and direct skin infection follow- ing a traumatic inoculation event (exposure inmoist wooded areas during outdoor activities, animal bites and scratches) are possible means of infection. Diagnosis of skin lesions in the cutaneous blastomycosis is challenging and requires a high index of suspicion. Skin
involvement generally begins as papules, postules, and or subcutaneous nodules and will develop into verrucous plaques or ulcers that may suppurate and spontaneously drain, forming deep cutaneous ulcers. 1 The differential diagnoses for such lesions includes but are not limited to pyoderma gangrenosum, squamous cell carcinoma, basal cell carcinoma, keratoacanthoma, and other chronic cutane- ous infections, such as sporotrichosis, nocardiosis, atypical mycobacteriosis, tularemia, anthrax, or leishmaniasis. 1,4 Visualization of the yeasts on 10% KOH preparation, Gomori’s stain, PAS stain, or Papanicolaou’s smear of tissue biopsy, tracheal aspirates, BAL fluid, and sputum specimens or tissue cytological analysis or fungal culture on Sabouraud dextrose agar at room temperature are some basic methods for diagnosis of the Blastomyces dermatitidis infections. 1 The organism appears as single or budding spherical cells (8- 15µm in diameter) with thick cell walls. Although micro- scopic visualization of broad-based budding yeast can be diagnostic, fungal cultures of skin biopsies should always be done, especially when microscopy is inconclusive. 1 Anti- cough, sputum) 15 months before. The CXR findings did not change following a two-week course of antibiotics. The patient subsequently underwent a broncoscopy and bron- choalveolar lavage (BAL) during which the right-upper, middle, and lower lobe segmental orifices were visualized to be non-inflamed. A right middle lobe transbronchial lung biopsy (fluoroscopic guidance) did not show any abnormal- ity, and the BAL was negative for malignancy and fungal cultures. The follow-up CXR did not show any change. The patient underwent resection of the skin lesionwhich showed pseudoepitheliomatous hyperplasia (Figure 2), presence of the budding yeast with a double-contoured wall (Figures 3,4) and confirmed a diagnosis of a cutaneous blastomycosis. Acid fast staining of the pathology specimen was negative. Patient was started on Itraconazole orally. Repeat CXR showed no active pulmonary disease.
248 J La State Med Soc VOL 166 November/December 2014
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