Commercial Mulch as a Potential Source of Blastomyces Dermatitides
Lalitha Kambhamettu, MD (Associate); Janine Jordan, MD (Member)
Christiana Care Health System, Newark, DE
Case Report: A 21-year old African-American male presented to the ED with a 1-month history of raised verrucous skin lesions on his face and right arm and 2-week history of headaches, fever, and episodic confusion. He was previously healthy and had spent the summer landscaping, during which time he had extensive contact with commercial mulch. He was raised in Tennessee and had moved to Delaware four years before admission. His temperature was 39 degrees. Cardiac, pulmonary, abdominal and neurologic exams were normal initially. On the third hospital day, he developed diplopia and R VI nerve palsy. An initial CT scan of the brain was negative. On LP, the opening pressure was 36 cms of water, glucose 27mg/dl; protein 238mg/dl; WBC 333cells/cu mm with 7 neutrophils and 81 lymphocytes. His HIV and PPD tests were negative. Skin biopsy of the lesions revealed non-caseating granulomas, with broad-based budding yeast on silver staining. Amphotericin B was initiated at a dose of 0.6 mg/Kg/day. Fungal culture of the skin lesion confirmed Blastomyces dermatitides after four weeks. He received a total dose of 2 grams of Amphotericin B and also underwent multiple lumbar punctures with drainage of CSF until intracranial pressures normalized. After resolution of his symptoms and reversal of his cranial nerve palsy, he was discharged with follow up.
Discussion: Blastomyces dermatitides is a thermal dimorphic fungus found in soil rich in decaying vegetation and animal feces, especially along waterways. Infection is usually confined to endemic areas, which in the United States are in the Midwest, Southeast, Western Pennsylvania and Northern NY regions. Infection is acquired via inhalation of the conidia; the lung is the primary focus. Involvement of the hilar lymph nodes provides access for further lymphohematogenous spread. Skin, bones, and prostate are the most common sites of systemic involvement. CNS involvement is present in only 5% of cases of disseminated blastomycosis in the immunocompetent host. Usual CNS manifestations are brain abscess or meningitis, the latter representing a late and delayed complication. This case of Blastomyces meningitis in our geographic location either represents a delayed manifestation of a latent infection acquired during his stay in the endemic region or raises the interesting possibility of acquisition of the infection through commercial mulch. We did not attempt to culture the commercial mulch for the fungus, because it is often difficult to isolate from the environment due to its extreme sensitivity to temperature changes. Clinicians should be aware of the enlarging ecologic niche of Blastomyces and include it in their differential diagnosis in the appropriate clinical setting.
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R. Bradley Slease, MD, FACP
Governor, Delaware Chapter
Cindy Chuidian
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