BlastomycosisGeoff McKee, MD

Resident Physician

Public Health and Preventive Medicine

University of British Columbia

http://cmr.asm.org/content/23/2/367.full.pdf

Not just a heavy metal band

...although potentially as hardcore

http://www.metal-archives.com/images/1/2/8/3/128324_logo.jpg?1645

Acknowledgements

Dr. Michelle Kates – primary veterinarian

Dr. Eleni Galenis – Zoonosis Lead, BCCDC

Dr. Linda Hoang – Medical Microbiologist, BCCDC

Dr. Mohammed Morshed – Medical Microbiologist, BCCDC

Dr. Theresa Burns - Public Health Veterinarian (involved in case)

Objectives

Review blastomycosis Epidemiology

Pathophysiology

Presentation

Management

Case 1: Canine Blastomycosis Infection Case 2: Red Panda Blastomycosis Infection (Dr.

Snyman) Discuss hazards of imported blastomycosis in BC

http://cmr.asm.org/content/23/2/367/F8.expansion.html

What is Blastomycosis?

A systemic pyogranulomatous infection endemic to regions of mid-western and eastern North America

Caused by Blastomyces spp.

First identified by Dr. T. Caspar Gilchrist, a dermatologist in Baltimore

http://www.photogravure.com/photogravure_images/large/Ulmann_03_32.jpg

Geographic Distribution

Eastern United States

Central Canada

Globally

Southeast Asia

Africa

Europe

Middle East

http://img.medscape.com/article/821/652/821652-figure.jpg

Environmental Factors

Typically exist in mycelial form in environment

Spores bound tightly to filaments and become unbound in presence of high humidity

Transmission typically associated with humid environments (Rivers, streams etc)

https://www.gov.mb.ca/mit/floodinfo/floodoutlook/images/pembina_river_above_lorne_lake.jpg

http://www.cdc.gov/fungal/images/blastomycosis-lifecycle.jpg

Hosts and Transmission

Hosts

Humans

Dogs, cats, foxes, pandas, lions etc

Transmission

Primarily through inhalation of airborne conidia

Cutaneous infection possible through direct inoculation

Pathophysiology

Conversion to yeast form dependant on temperature and nutrients

http://www.cdc.gov/fungal/images/blastomycosis-lifecycle.jpg

Clinical Disease

Presentation

Pulmonary

Cutaneous

Treatment

Mild Disease

Azoles -> itraconazole etc.

Moderate to Severe Disease

Amphoteracin B

López-Martínez, R., & Méndéz-Tovar, L. J. (2012).

Systemic Illness involving other organs

Brömel, C., & Sykes, J. E. (2005)

Case 1 – Initial Presentation

1.5 year old Portuguese Water Dog presented to vet in January 2015 for skin lesions on its back.

Diagnosed with sterile nodular panniculitis on biopsy with negative bacterial cultures

Treated with steroids

Case 1 – A turn for the worse

Developed fulminant illness compatible with blastomycosis (fever, respiratory distress, enlarged lymph nodes)

Lymph node aspirate sent for testing - Blastomyces visualized on microscopy and confirmed via PCR

*Not from actual specimanhttp://cmr.asm.org/content/23/2/367.full.pdf

Case 1 – Pulmonary Infiltrates

Before Steroids After Steroids

Case 1 – Treatment and Recovery

The dog was started on fluconazole and, following an increase in dose, improved dramatically.

Likely to test urine for Blastomyces antigen prior to halting treatment

Case 1 – Reporting to Public Health

BCCDC was notified following the diagnosis of blastomycosis

A repeat lymph node aspirate was obtained by PHSA labs and the diagnosis was confirmed on microscopy. Blastomyces was also cultured from the sample.

Case 1 - Public Health Investigation

Exposure History

Traveled via car to southwestern Manitoba 6 months prior to the onset of symptoms. While in Manitoba, the dog swam in a river.

Travel in BC was also documented with trips to the Interior, Vancouver Island and various locations on the lower mainland.

Travel to Washington State also documented

The dog lived in a condo in Vancouver, with no backyard.

http://www.gov.mb.ca/health/rha/map.html

Case 1 – Considering the Evidence

Considering likelihood of exposures:

Blastomycosis endemic to Manitoba (particularly eastern Manitoba) and likely Saskatchewan

No cases of locally acquired blastomycosis reported in British Columbia

No evidence of local acquisition of blastomycosis in Washington State (although exposure history of several cases unclear as per consultation with WA Public Health)

Case 1 - Conclusion

Blastomyces likely acquired during trip to Manitoba

Unable to prove or disprove acquisition in British Columbia

Further investigation required if subsequent cases arise in BC with uncertain exposure histories

Thank you to Dr. Kates for granting permission to use case photos

References Baily, G. G., Robertson, V. J., Neill, P., Garrido, P., & Levy, L. F. (1991). Blastomycosis in Africa: Clinical Features, Diagnosis, and Treatment. Clinical Infectious Diseases, 13(5), 1005–1008.

http://doi.org/10.1093/clinids/13.5.1005

Bernstein, S., Brunner, H. I., Summerbell, R., Allen, U., Babyn, P., & Richardson, S. E. (2002). Blastomycosis acquired by three children in Toronto. The Canadian Journal of Infectious Diseases = Journal Canadien Des Maladies Infectieuses , 13(4), 259–63. Retrieved from /pmc/articles/PMC2094876/?report=abstract

Bialek, R., Ibricevic, A., Fothergill, A., & Begerow, D. (2000). Small Subunit Ribosomal DNA Sequence Shows Paracoccidioides brasiliensis Closely Related to Blastomyces dermatitidis. J. Clin. Microbiol., 38(9), 3190–3193. Retrieved from http://jcm.asm.org.ezproxy.library.ubc.ca/content/38/9/3190.short

Brömel, C., & Sykes, J. E. (2005). Epidemiology, diagnosis, and treatment of blastomycosis in dogs and cats. Clinical Techniques in Small Animal Practice, 20(4), 233–9. http://doi.org/10.1053/j.ctsap.2005.07.004

Brown, E. M., McTaggart, L. R., Zhang, S. X., Low, D. E., Stevens, D. A., & Richardson, S. E. (2013). Phylogenetic analysis reveals a cryptic species Blastomyces gilchristii, sp. nov. within the human pathogenic fungus Blastomyces dermatitidis. PloS One, 8(3), e59237. http://doi.org/10.1371/journal.pone.0059237

Chapman, S. W., Dismukes, W. E., Proia, L. A., Bradsher, R. W., Pappas, P. G., Threlkeld, M. G., & Kauffman, C. A. (2008). Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America , 46(12), 1801–12. http://doi.org/10.1086/588300

Crampton, T. L., Light, R. B., Berg, G. M., Meyers, M. P., Schroeder, G. C., Hershfield, E. S., & Embil, J. M. (2002). Epidemiology and clinical spectrum of blastomycosis diagnosed at Manitoba hospitals. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America , 34(10), 1310–6. http://doi.org/10.1086/340049

Davies, J. L., Epp, T., & Burgess, H. J. (2013). Prevalence and geographic distribution of canine and feline blastomycosis in the Canadian prairies. The Canadian Veterinary Journal. La Revue Vétérinaire Canadienne, 54(8), 753–60. Retrieved from /pmc/articles/PMC3711163/?report=abstract

Government of Canada, P. H. A. of C. (2011). Blastomyces dermatitidis - Pathogen Safety Data Sheets. Retrieved from http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/blastomyces-dermatitidis-eng.php#footnote2

Hannah, E. L., Bailey, A. M., Hajjeh, R., Gershman, K., Lindsley, M., & Hoffman, R. E. (2001). Public health response to 2 clinical cases of blastomycosis in colorado residents. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America , 32(11), E151–3. http://doi.org/10.1086/320516

http://doi.org/10.1023/B:MYCO.0000003558.71489.01

References

Hay, R. (2000). Blastomycosis: what’s new? Journal of the European Academy of Dermatology and Venereology, 14(4), 249–250. http://doi.org/10.1046/j.1468-3083.2000.00098.x

Herrmann, J. A., Kostiuk, S. L., Dworkin, M. S., & Johnson, Y. J. (2011). Temporal and spatial distribution of blastomycosis cases among humans and dogs in Illinois (2001-2007). Journal of the American Veterinary Medical Association, 239(3), 335–43. http://doi.org/10.2460/javma.239.3.335

Johnson, L. B., & Kauffman, C. A. (2003). Voriconazole: a new triazole antifungal agent. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 36(5), 630–7. http://doi.org/10.1086/367933

Klein, B. S., Vergeront, J. M., Disalvo, A. F., Kaufman, L., & Davis, J. P. (2012). Two Outbreaks of Blastomycosis Along Rivers in Wisconsin: Isolation of Blastomyces dermatitidis from Riverbank Soil and Evidence of its Transmission Along Waterways. American Review of Respiratory Disease. Retrieved from http://www.atsjournals.org.ezproxy.library.ubc.ca/doi/abs/10.1164/ajrccm/136.6.1333#.VVONPY5VhBc

López-Martínez, R., & Méndéz-Tovar, L. J. (2012). Blastomycosis. Clinics in Dermatology, 30(6), 565–72. http://doi.org/10.1016/j.clindermatol.2012.01.002

McCullough, M. J., DiSalvo, A. F., Clemons, K. V, Park, P., & Stevens, D. A. (2000). Molecular epidemiology of Blastomyces dermatitidis. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America , 30(2), 328–35. http://doi.org/10.1086/313649

McDonough, E. S., Wisniewski, T. R., Penn, L. A., Chan, D. M., & McNamara, W. J. (1976). Preliminary studies on conidial liberation of Blastomyces dermatitidis and Histoplasma capsulatum. Medical Mycology, 14(2), 199–204. http://doi.org/10.1080/00362177685190271

Pfaller, M. A., & Diekema, D. J. (2010). Epidemiology of invasive mycoses in North America. Critical Reviews in Microbiology, 36(1), 1–53. http://doi.org/10.3109/10408410903241444

Public Health and Primary Health Care Division. (2013). Manitoba Annual Summary of Communicable Diseases. Retrieved from http://www.gov.mb.ca/health/publichealth/surveillance/cds/docs/2013.pdf

Reed, K. D., Meece, J. K., Archer, J. R., & Peterson, A. T. (2008). Ecologic niche modeling of Blastomyces dermatitidis in Wisconsin. PloS One, 3(4), e2034. http://doi.org/10.1371/journal.pone.0002034

Rodriguez, R. C., Cornock, E., White, V. A., & Dolman, P. J. (2012). Eyelid blastomycosis in British Columbia. Canadian Journal of Ophthalmology. Journal Canadien D’ophtalmologie, 47(3), e1–2. http://doi.org/10.1016/j.jcjo.2012.03.008

Salas-Alanis, J. C., Martinez, M. F., Garcia-Melendez, M., Gonzalez, B. L., & Ocampo-Candiani, J. (2013). Blastomycosis imported to Monterrey, Mexico: fifth case reported in Mexico. Mycoses, 56(4), 495–7. http://doi.org/10.1111/myc.12051

Seitz, A. E., Younes, N., Steiner, C. A., & Prevots, D. R. (2014). Incidence and trends of blastomycosis-associated hospitalizations in the United States. PloS One, 9(8), e105466. http://doi.org/10.1371/journal.pone.0105466

Storms, T. N., Clyde, V. L., Munson, L., & Ramsay, E. C. (2003). BLASTOMYCOSIS IN NONDOMESTIC FELIDS. Journal of Zoo and Wildlife Medicine, 34(3), 231–238. http://doi.org/10.1638/1042-7260(2003)034[0231:BINF]2.0.CO;2

References

Vasquez, J. E. (1998). Blastomycosis in Northeast Tennessee. CHEST Journal, 114(2), 436. http://doi.org/10.1378/chest.114.2.436

Velázquez, R., Muñoz-Hernández, B., Arenas, R., Taylor, M. L., Hernández-Hernández, F., Manjarrez, M. E., & López-Martínez, R. (2003). An Imported Case of Blastomyces Dermatitidis Infection in Mexico. Mycopathologia, 156(4), 263–267.