para>Azoles should be avoided in pregnancy because of potential teratogenesis.
Lipid formulation AmB 3 to 5 mg/kg/day (7)[C]
Pediatric Considerations
Newborn infection: AmB deoxycholate, 1 mg/kg/day (7)[C]
Children with severe blastomycosis: AmB deoxycholate, 0.7 to 1 mg/kg/day, or lipid formulation AmB, at 3 to 5 mg/kg/day, followed by itraconazole, 10 mg/kg/day (up to 400 mg/day) as step-down therapy, for a total of 12 months (7)[C]
Children with mild to moderate infections: Oral itraconazole, 10 mg/kg/day (up to 400 mg/day PO) for 6 to 12 months, is recommended (7)[C].
SURGERY/OTHER PROCEDURES
- Drain abscess; empyema
- D ©bride bone lesions.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- ARDS, respiratory failure, hypoxia, severe pneumonia
- CNS involvement
- Adjuvant surgical treatment needed
- Immunocompromised patients with significant disease
- ICU if unstable
- Consider infectious disease consultation.
Discharge Criteria
Clinically stable and responding to therapy
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- All azoles have been reported to cause hepatitis; hepatic enzymes should be measured before initiating and again periodically during therapy.
- Reactivation may occur with or without treatment.
PROGNOSIS
- Delay in diagnosis results in increased morbidity and mortality
- Cure in >90% of uncomplicated cases
- Relapse may occur.
- Immunosuppressed and AIDS patients and CNS blastomycosis have a worse prognosis.
COMPLICATIONS
- Fulminant multilobar pneumonia, ARDS
- Meningoencephalitis
- Osteomyelitis
- Permanent lung damage with chronic disease
REFERENCES
11 Smith JA, Kauffman CA. Blastomycosis. Proc Am Thorac Soc. 2010;7(3):173-180.22 Brown EM, McTaggart LR, Zhang SX, et al. Phylogenetic analysis reveals a cryptic species Blastomyces gilchristii, sp. nov. within the human pathogenic fungus Blastomyces dermatitidis. PLoS One. 2013;8(3):e59237.33 Baumgardner DJ, Bernhard KA, Egan G. Pulmonary blastomycosis in Vilas County, Wisconsin: Weather, exposures and symptoms. J Patient-Centered Res Rev. 2015;2(1):25-33.44 Bariola JR, Vyas KS. Pulmonary blastomycosis. Semin Respir Crit Care Med. 2011;32(6):745-753.55 Bush JW, Wuerz T, Embil JM, et al. Outcomes of persons with blastomycosis of the central nervous system. Diag Microbiol Infect Dis. 2013;76(2):175-181.66 Baumgardner DJ, Temte JL, Gutowski E, et al. The differential diagnosis of pulmonary blastomycosis using case vignettes: a Wisconsin Network for Health Research (WiNHR) study. WMJ. 2011;110(2):68-73.77 Chapman SW, Dismukes WE, Proia LA, et al. Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2008;46(12):1801-1812.88 Plamondon M, Lamontagne F, Allard C, et al. Corticosteroids as an adjunctive therapy in severe blastomycosis-induced acute respiratory distress syndrome. Clin Infect Dis. 2010;51(1):e1-e3.
CODES
ICD10
- B40.9 Blastomycosis, unspecified
- B40.2 Pulmonary blastomycosis, unspecified
- B40.7 Disseminated blastomycosis
- B40.3 Cutaneous blastomycosis
- B40.81 Blastomycotic meningoencephalitis
- B40.89 Other forms of blastomycosis
- B40.0 Acute pulmonary blastomycosis
- B40.1 Chronic pulmonary blastomycosis
ICD9
116.0 Blastomycosis
SNOMED
- Blastomycosis (disorder)
- Pulmonary blastomycosis (disorder)
- Disseminated blastomycosis (disorder)
- Cutaneous blastomycosis
- Blastomyces infection of central nervous system
CLINICAL PEARLS
- Consider blastomycosis in patients presenting with flulike respiratory illness. Also, consider blastomycosis for patients with overwhelming pneumonia and in the differential of cases of apparent antibiotic failure in the setting of routine community-acquired pneumonia.
- Sputum examination with KOH for rapid identification of Blastomyces buds is a reasonable initial diagnostic option.
- AmB and itraconazole remain the primary drugs of choice for treatment of blastomycosis.