History

Fact Explanation
History of residing in or travelling to an endemic area Blastomycosis is a common zoonotic fungal infection in endemic areas, like border of the Great Lakes, St. Lawrence River, the Mississippi River and Ohio River. [1] Human infection is common in those areas, and occurs when airborne conidia are inhaled from the soil. [1] [2] [3] If the contacted person's immunity fights against the fungus, it can be contained, but if not, the dimorphic fungus develops into the yeast form [4] and the yeast forms migrate to other sites through blood and lymphatic system. [1] [5] [6] Lungs are the most common initially affected organ. [7]
An associated immunodeficiency status. It has been reported that there is a high incidence of blastomycosis in patients who are immunosuppressed, or obese or diabetic. [8] [9] [10] [11]
Fever, productive cough, shortness of breath and chest pain. The causative yeast Blastomyces dermatitidis [12] initiates an inflammatory reaction in the lungs somewhat similar to bacterial pneumonia in presentation. [5] [13] It may be self-limited [4], or mimic acute bacterial pneumonia, or even progress to indolent or chronic stages. [13] Pneumonia is the most common manifestation of blastomycosis. [7] The initial response to the yeast is suppurative [14], hence acute fever, productive cough with purulent sputum and pleuritic type chest pain can be justified. Some cases have been known to mimic bronchogenic carcinoma. [15]
Rapidly deteriorating shortness of breath Some cases progress to overwhelming blastomycosis and Acute Respiratory Distress Syndrome. [16] [17] Even though the mortality rate can go up as much as 80%, once treated they have a good prognosis. [18] It was uncovered that there was an association between obesity and shorter incubation period with the risk of developing into ARDS. [8] [19]
Other systemic complaints i.e. bone, endocrine glands, skin rashes Due to disseminated blastomycosis. The site it spreads to is unpredictable, and the non-specific symptoms might be the first presentation. There have been various disseminated sited reported throughout the history of research. [20] [21] [22] [23]
History of maternal blastomycosis in pregnancy Blastomycosis can be transmitted through the placenta, but it happens so not in all cases. The complications of blastomycosis in pregnancy is more to the infant/fetus than the mother. There have been reported stillbirths, disseminated miliary blastomycosis. [24] [25] [26]
Asymptomatic Some patients are asymptomatic and the findings are incidental. [1] [15]
References
  1. SACCENTE M., WOODS G. L.. Clinical and Laboratory Update on Blastomycosis. Clinical Microbiology Reviews [online] December, 23(2):367-381 [viewed 16 May 2014] Available from: doi:10.1128/CMR.00056-09
  2. KLEIN BS, VERGERONT JM, WEEKS RJ, KUMAR UN, MATHAI G, VARKEY B, KAUFMAN L, BRADSHER RW, STOEBIG JF, DAVIS JP. Isolation of Blastomyces dermatitidis in soil associated with a large outbreak of blastomycosis in Wisconsin. N Engl J Med [online] 1986 Feb 27, 314(9):529-34 [viewed 16 May 2014] Available from: doi:10.1056/NEJM198602273140901
  3. BACHIR J, FITCH GL. Northern Wisconsin married couple infected with blastomycosis. WMJ [online] 2006 Sep, 105(6):55-7 [viewed 16 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17042422
  4. TENENBAUM MARVIN J., GREENSPAN JOEL, KERKERING THOMAS M., UTZ JOHN P.. Blastomycosis. Critical Reviews in Microbiology [online] 1982 January, 9(3):139-163 [viewed 16 May 2014] Available from: doi:10.3109/10408418209104489
  5. BEDIMO ROGER, WEINSTEIN JEFFREY. A 19‐Year‐Old Woman with Fever, Rash, and a Pulmonary Infiltrate. CLIN INFECT DIS [online] 2001 November, 33(10):1770-1771 [viewed 16 May 2014] Available from: doi:10.1086/338216
  6. NEMECEK JC, WüTHRICH M, KLEIN BS. Global control of dimorphism and virulence in fungi. Science [online] 2006 Apr 28, 312(5773):583-8 [viewed 16 May 2014] Available from: doi:10.1126/science.1124105
  7. BRADSHER R. W.. Blastomycosis. Clinical Infectious Diseases [online] 1992 March, 14(Supplement 1):S82-S90 [viewed 16 May 2014] Available from: doi:10.1093/clinids/14.Supplement_1.S82
  8. LEMOS LB, BALIGA M, GUO M. Blastomycosis: The great pretender can also be an opportunist. Initial clinical diagnosis and underlying diseases in 123 patients. Ann Diagn Pathol [online] 2002 Jun, 6(3):194-203 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12089732
  9. SAROSI GA, DAVIES SF. Endemic mycosis complicating human immunodeficiency virus infection. West J Med [online] 1996 Apr, 164(4):335-40 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8732733
  10. WHEAT J. Endemic mycoses in AIDS: a clinical review. Clin Microbiol Rev [online] 1995 Jan, 8(1):146-59 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7704892
  11. DUPONT B. [Exotic pulmonary mycoses]. Rev Pneumol Clin [online] 1998 Dec, 54(6):301-8 [viewed 17 May 2014] Available from: Doi : RP-12-1998-54-6-0761-8417-101019-ART65
  12. PATEL AJAY JITENDRA, GATTUSO PAOLO, REDDY VIJAYA B.. Diagnosis of Blastomycosis in Surgical Pathology and Cytopathology: Correlation With Microbiologic Culture. The American Journal of Surgical Pathology [online] 2010 February, 34(2):256-261 [viewed 16 May 2014] Available from: doi:10.1097/PAS.0b013e3181ca48a5
  13. BRADSHER ROBERT. Pulmonary Blastomycosis. Semin Respir Crit Care Med [online] 2008 April, 29(2):174-181 [viewed 16 May 2014] Available from: doi:10.1055/s-2008-1063856
  14. BRADSHER R. W.. Histoplasmosis and Blastomycosis. Clinical Infectious Diseases [online] 1996 May, 22(Supplement 2):S102-S111 [viewed 16 May 2014] Available from: doi:10.1093/clinids/22.Supplement_2.S102
  15. BARIOLA J., VYAS KEYUR. Pulmonary Blastomycosis. Semin Respir Crit Care Med [online] December, 32(06):745-753 [viewed 16 May 2014] Available from: doi:10.1055/s-0031-1295722
  16. MEYER KC, MCMANUS EJ, MAKI DG. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. N Engl J Med [online] 1993 Oct 21, 329(17):1231-6 [viewed 17 May 2014] Available from: doi:10.1056/NEJM199310213291704
  17. WARE LORRAINE B., MATTHAY MICHAEL A.. The Acute Respiratory Distress Syndrome. N Engl J Med [online] 2000 May, 342(18):1334-1349 [viewed 17 May 2014] Available from: doi:10.1056/NEJM200005043421806
  18. DALTON HEIDI J, HERTZOG JAMES H, HANNAN ROBERT L, VEZZA PHYLLIS, HAUSER GABRIEL J. Extracorporeal membrane oxygenation for overwhelming Blastomyces dermatitidis pneumonia. Crit Care [online] 1999 December [viewed 17 May 2014] Available from: doi:10.1186/cc349
  19. PARMAR MS. Paradise - not without its plagues: Overwhelming Blastomycosis pneumonia after visit to lakeside cottages in Northeastern Ontario BMC Infect Dis [online] :30 [viewed 17 May 2014] Available from: doi:10.1186/1471-2334-5-30
  20. RAO GRAGHURAMA, NARAYAN BETSYLAKSHMI, DURGA PRASAD BK, SRIDEVI M, RAJU BUCHI, AMARESWAR A. Disseminated blastomycosis in a child with a brief review of the Indian literature. Indian J Dermatol Venereol Leprol [online] 2013 December [viewed 17 May 2014] Available from: doi:10.4103/0378-6323.104676
  21. HARVEY AM, MODY DR, AMRIKACHI M. Disseminated blastomycosis diagnosed by fine-needle aspiration of the thyroid. Diagn Cytopathol [online] 2011 Jun, 39(6):446-50 [viewed 17 May 2014] Available from: doi:10.1002/dc.21466
  22. SOLWAY LJ, KOHAN M, PRITZKER HG. A Case Of Disseminated Blstomycosis. Can Med Assoc J [online] 1939 Oct, 41(4):331-336 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC537506
  23. MONACO WE, BATSIS JA. A case of disseminated blastomycosis in Vermont. Diagn Microbiol Infect Dis [online] 2013 Apr, 75(4):423-5 [viewed 17 May 2014] Available from: doi:10.1016/j.diagmicrobio.2013.01.010
  24. DANIEL L, SALIT IE. Blastomycosis during pregnancy. Can Med Assoc J [online] 1984 Oct 1, 131(7):759-61 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6478365
  25. LEMOS LUCIANO B., SOOFI MAHDIA, AMIR EMRAN. Blastomycosis and pregnancy. Annals of Diagnostic Pathology [online] 2002 August, 6(4):211-215 [viewed 17 May 2014] Available from: doi:10.1053/adpa.2002.34729
  26. PIPITONE MICHELLE A., GLOSTER HUGH M.. A case of blastomycosis in pregnancy. Journal of the American Academy of Dermatology [online] 2005 October, 53(4):740-741 [viewed 17 May 2014] Available from: doi:10.1016/j.jaad.2005.04.018

Examination

Fact Explanation
Febrile The inflammatory response to fungal infection. The fever can be high, similar to acute bacterial pneumonia. [1] [2] [3] [4]
Evidence of lung consolidation or cavitation Pulmonary blastomycosis can mimic acute bacterial pneumonia, chronic pneumonia, tuberculosis or even bronchial carcinoma, which are more common clinical entities with similar findings. [1] [2] [3] [4] [5] [6]
Tachypnea, cyanosis The infection developing into overwhelming blastomycosis and acute respiratory distress syndrome. [7] [8] [9] [10]
Skin rash There have been reported cases of skin rashes associated with pulmonary blastomycosis. [11] [12] [13]
References
  1. SACCENTE M., WOODS G. L.. Clinical and Laboratory Update on Blastomycosis. Clinical Microbiology Reviews [online] December, 23(2):367-381 [viewed 16 May 2014] Available from: doi:10.1128/CMR.00056-09
  2. BEDIMO ROGER, WEINSTEIN JEFFREY. A 19‐Year‐Old Woman with Fever, Rash, and a Pulmonary Infiltrate. CLIN INFECT DIS [online] 2001 November, 33(10):1770-1771 [viewed 16 May 2014] Available from: doi:10.1086/338216
  3. PATEL AJAY JITENDRA, GATTUSO PAOLO, REDDY VIJAYA B.. Diagnosis of Blastomycosis in Surgical Pathology and Cytopathology: Correlation With Microbiologic Culture. The American Journal of Surgical Pathology [online] 2010 February, 34(2):256-261 [viewed 16 May 2014] Available from: doi:10.1097/PAS.0b013e3181ca48a5
  4. BRADSHER R. W.. Histoplasmosis and Blastomycosis. Clinical Infectious Diseases [online] 1996 May, 22(Supplement 2):S102-S111 [viewed 16 May 2014] Available from: doi:10.1093/clinids/22.Supplement_2.S102
  5. BRADSHER R. W.. Blastomycosis. Clinical Infectious Diseases [online] 1992 March, 14(Supplement 1):S82-S90 [viewed 16 May 2014] Available from: doi:10.1093/clinids/14.Supplement_1.S82
  6. BARIOLA J., VYAS KEYUR. Pulmonary Blastomycosis. Semin Respir Crit Care Med [online] December, 32(06):745-753 [viewed 16 May 2014] Available from: doi:10.1055/s-0031-1295722
  7. MEYER KC, MCMANUS EJ, MAKI DG. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. N Engl J Med [online] 1993 Oct 21, 329(17):1231-6 [viewed 17 May 2014] Available from: doi:10.1056/NEJM199310213291704
  8. WARE LORRAINE B., MATTHAY MICHAEL A.. The Acute Respiratory Distress Syndrome. N Engl J Med [online] 2000 May, 342(18):1334-1349 [viewed 17 May 2014] Available from: doi:10.1056/NEJM200005043421806
  9. DALTON HEIDI J, HERTZOG JAMES H, HANNAN ROBERT L, VEZZA PHYLLIS, HAUSER GABRIEL J. Extracorporeal membrane oxygenation for overwhelming Blastomyces dermatitidis pneumonia. Crit Care [online] 1999 December [viewed 17 May 2014] Available from: doi:10.1186/cc349
  10. PARMAR MS. Paradise - not without its plagues: Overwhelming Blastomycosis pneumonia after visit to lakeside cottages in Northeastern Ontario BMC Infect Dis [online] :30 [viewed 17 May 2014] Available from: doi:10.1186/1471-2334-5-30
  11. BEDIMO ROGER, WEINSTEIN JEFFREY. A 19‐Year‐Old Woman with Fever, Rash, and a Pulmonary Infiltrate. CLIN INFECT DIS [online] 2001 November, 33(10):1770-1771 [viewed 16 May 2014] Available from: doi:10.1086/338216
  12. JAIN A, JAIN S, RAWAT S. Emerging fungal infections among children: A review on its clinical manifestations, diagnosis, and prevention J Pharm Bioallied Sci [online] 2010, 2(4):314-320 [viewed 17 May 2014] Available from: doi:10.4103/0975-7406.72131
  13. GUARNER J, BRANDT ME. Histopathologic Diagnosis of Fungal Infections in the 21st Century Clin Microbiol Rev [online] 2011 Apr, 24(2):247-280 [viewed 17 May 2014] Available from: doi:10.1128/CMR.00053-10

Differential Diagnoses

Fact Explanation
Acute baterial pneumonia The acute pulmonary blastomycosis initiates an acute inflammatory reaction in lung parenchyma which is clinically similar to acute bacterial pneumonia. The clinical presentation can be difficult to differentiate, and often patients are treated with antibiotics before diagnosis. [1] [2] Acute pneumonia is the most common manifestation of blastomycosis. [3] When there are epidemics, and there is a travel history to endemic areas, blastomycosis should be suspected in patients with chest infections. [4]
Pulmonary tuberculosis Pulmonary blastomycosis can mimic pulmonary tuberculosis since both have a sub-acute onset of clinical symptoms. Blastomycosis in chronicity can present with weight loss, night sweats and other non-specific symptoms together with chest symptoms making it an easy mistake to misdiagnose as pulmonary tuberculosis. Other way around, tuberculosis causes a drop in immunity and fungal infections can occur in higher incidences in those who are immunocompromised. [2] [5] [6] [7] [8] [9] The possible explanation is that both conditions cause a chronic granulomatous inflammation in the lung, but in blastomycosis, a non-caseating one. [7] [8] [10]
Bronchogenic carcinoma Since blastomycosis can present in a variety of syndromes, one important differential in lung malignancy. The subacute form of the infection might be difficult to differentiate from bronchogenic carcinoma. [2] [11] [12] [13] [14] [15] [16] [17][18]
References
  1. BEDIMO ROGER, WEINSTEIN JEFFREY. A 19‐Year‐Old Woman with Fever, Rash, and a Pulmonary Infiltrate. CLIN INFECT DIS [online] 2001 November, 33(10):1770-1771 [viewed 16 May 2014] Available from: doi:10.1086/338216
  2. BRADSHER ROBERT. Pulmonary Blastomycosis. Semin Respir Crit Care Med [online] 2008 April, 29(2):174-181 [viewed 16 May 2014] Available from: doi:10.1055/s-2008-1063856
  3. BRADSHER R. W.. Blastomycosis. Clinical Infectious Diseases [online] 1992 March, 14(Supplement 1):S82-S90 [viewed 16 May 2014] Available from: doi:10.1093/clinids/14.Supplement_1.S82
  4. BRADSHER R. W.. Histoplasmosis and Blastomycosis. Clinical Infectious Diseases [online] 1996 May, 22(Supplement 2):S102-S111 [viewed 16 May 2014] Available from: doi:10.1093/clinids/22.Supplement_2.S102
  5. GILLIES M. A Case Of Blastomycosis. Can Med Assoc J [online] 1933 Aug, 29(2):183-185 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC402973
  6. MEDLAR EM. Pulmonary Blastomycosis; its Similarity to Tuberculosis. Report of Two Cases Am J Pathol [online] 1927 Jul, 3(4):305-314.9 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1931810
  7. BAKER RD. Tissue Reactions in Human Blastomycosis: An Analysis of Tissue from Twenty-Three Cases Am J Pathol [online] 1942 May, 18(3):479-497 [viewed 18 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2032963
  8. MILLER WS. The Reticulum of the Lung: V. Its Similarity in Blastomycosis to That in Tuberculosis Am J Pathol [online] 1927 Jul, 3(4):315-320.7 [viewed 18 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1931813
  9. MCLAREN JA. North American Blastomycosis. Can Med Assoc J [online] 1949 Jan, 60(1):26-32 [viewed 18 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1591392
  10. LASKEY WARREN. Endogenous Activation in Blastomycosis. Ann Intern Med [online] 1978 January [viewed 18 May 2014] Available from: doi:10.7326/0003-4819-88-1-50
  11. VAHID B, WILDEMORE B, NGUYEN C, SISTRUN N, MARIK PE. Pulmonary blastomycosis masquerading as metastatic disease in the lung: a case report. MedGenMed [online] 2006 Jan 31, 8(1):31 [viewed 18 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16915161
  12. WALLEN ELLEN B., YOUNGBERG GEORGE A.. Blastomycosis. N Engl J Med [online] 1997 April, 336(17):1223-1223 [viewed 18 May 2014] Available from: doi:10.1056/NEJM199704243361705
  13. SACCENTE M, WOODS GL. Clinical and Laboratory Update on Blastomycosis Clin Microbiol Rev [online] 2010 Apr, 23(2):367-381 [viewed 18 May 2014] Available from: doi:10.1128/CMR.00056-09
  14. MARTYNOWICZ MAREK A.. Pulmonary Blastomycosis: an appraisal of diagnostic techniques. Chest [online] 2002 March [viewed 18 May 2014] Available from: doi:10.1378/chest.121.3.768
  15. BAUMGARDNER DJ, TEMTE JL, GUTOWSKI E, AGGER WA, BAILEY H, BURMESTER JK, BANERJEE I. The differential diagnosis of pulmonary blastomycosis using case vignettes: a Wisconsin Network for Health Research (WiNHR) study. WMJ [online] 2011 Apr, 110(2):68-73 [viewed 18 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21560560
  16. DALL BELLO AG, SEVERO CB, DE MATTOS OLIVEIRA F, SEVERO LC. Disseminated Paracoccidioidomycosis (Simulating Metastatic Lung Cancer) and Strongyloides stercoralis Hyperinfestation in a Steroid-Treated Patient J Clin Microbiol [online] 2011 May, 49(5):2054-2055 [viewed 18 May 2014] Available from: doi:10.1128/JCM.00025-11
  17. FANG WAYNE, WASHINGTON LACEY, KUMAR NIDHI. Imaging Manifestations of Blastomycosis: A Pulmonary Infection with Potential Dissemination1. RadioGraphics [online] 2007 May, 27(3):641-655 [viewed 18 May 2014] Available from: doi:10.1148/rg.273065122
  18. REDER PAUL A., NEEL H. BRYAN. Blastornycosis in Otolaryngology. The Laryngoscope [online] 1993 January [viewed 18 May 2014] Available from: doi:10.1288/00005537-199301000-00010

Investigations - for Diagnosis

Fact Explanation
Wet smears for microscopy. Direct examination of respiratory secretions (sputum, tracheal secretions, gastric washings) with potassium hydroxide solution helps visualizing the yeast. It's quicker than culture but not as accurate as it. [1] [2] [3] [4]
Sputum culture and miscroscopy The positive yield from the cultures are high and it's the method of definitive diagnosis. But it takes around 5 weeks to get the culture reports. [1] [2] [3] [4]
Chest radiography Radiography is not diagnostic but the extent and severity of blastomycosis pneumonitis can be appreciated. The expected signs are pulmonary infiltrates, the distribution and parenchymal patterns of disease, and the prevalence of lymphadenopathy, pleural effusions, and cavity formations. [5] [6]
Antigen testing Using immunoassay methods. It has yielded very satisfactory results, and novel ways are still under investigation. [7] [8]
References
  1. ROBERTSON SA, KIMBALL PL, MAGTIBAY LZ. Pulmonary blastomycosis diagnosed by cytologic examination of sputum. Can Med Assoc J [online] 1982 Feb 15, 126(4):387-388 [viewed 18 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1862869
  2. MARTYNOWICZ MAREK A.. Pulmonary Blastomycosis: an appraisal of diagnostic techniques. Chest [online] 2002 March [viewed 18 May 2014] Available from: doi:10.1378/chest.121.3.768
  3. WALLACE JEANNE. Pulmonary Blastomycosis: a great masquerader. Chest [online] 2002 March [viewed 18 May 2014] Available from: doi:10.1378/chest.121.3.677
  4. TRUMBULL MERLIN L.. The Cytological Diagnosis of Pulmonary Blastomycosis. JAMA [online] 1981 February [viewed 18 May 2014] Available from: doi:10.1001/jama.1981.03310330026018
  5. SHEFLIN JR, CAMPBELL JA, THOMPSON GP. Pulmonary blastomycosis: findings on chest radiographs in 63 patients. AJR Am J Roentgenol [online] 1990 Jun, 154(6):1177-80 [viewed 18 May 2014] Available from: doi:10.2214/ajr.154.6.2110723
  6. ALKRINAWI S, REED M H, PASTERKAMP H. Pulmonary blastomycosis in children: findings on chest radiographs.. American Journal of Roentgenology [online] 1995 September, 165(3):651-654 [viewed 18 May 2014] Available from: doi:10.2214/ajr.165.3.7645488
  7. DURKIN M, WITT J, LEMONTE A, WHEAT B, CONNOLLY P. Antigen Assay with the Potential To Aid in Diagnosis of Blastomycosis J Clin Microbiol [online] 2004 Oct, 42(10):4873-4875 [viewed 18 May 2014] Available from: doi:10.1128/JCM.42.10.4873-4875.2004
  8. CONNOLLY P, HAGE CA, BARIOLA JR, BENSADOUN E, RODGERS M, BRADSHER RW JR, WHEAT LJ. Blastomyces dermatitidis Antigen Detection by Quantitative Enzyme Immunoassay Clin Vaccine Immunol [online] 2012 Jan, 19(1):53-56 [viewed 18 May 2014] Available from: doi:10.1128/CVI.05248-11

Management - General Measures

Fact Explanation
Notification Blastomycosis usually erupts as epidemics since the yeast coccidia are airborne. It is also an occupational hazard in the health-care personnels and the staff involved in postmortem examinations. It is necessary to report on diagnosis and take necessary public health measures as indicated.
References
  1. MACDONALD PDM, LANGLEY RL, GERKIN SR, TOROK MR and MACCORMACK JN. Human and canine pulmonary blastomycosis, North Carolina, 2001–2002. Emerg Infect Dis [online]. 2006 Aug [16 May 2014]. http://dx.doi.org/10.3201/eid1208.050781

Management - Specific Treatments

Fact Explanation
Observation The patients who recover spontaneously and asympatomatic patients who may be diagnosed afterwards, require no treatment but need careful observation. [1]
Antifungals the patients who have symptomatic disease or the immunocompromised, who have a risk for overwhelming infection and ARDS require treatment with anti fungals. [1] The drug of choice for the immunocompromised, in those who have failed to eradicate the infection with conventional antifungals is amphotericin B. [1] [2] [3] [4] [5] [6] Azoles are less effcetive [7] but less toxic. i.e. ketoconazole, itraconazole, and fluconazole. [1] [6] Intravenous antifungals can be used in severe disease. [8]
References
  1. CHAPMAN SW, BRADSHER RW JR, CAMPBELL GD JR, PAPPAS PG, KAUFFMAN CA. Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of America. Clin Infect Dis [online] 2000 Apr, 30(4):679-83 [viewed 19 May 2014] Available from: doi:10.1086/313750
  2. ARIANO R. E., MITCHELMORE B. R., LAGACE-WIENS P. R., ZELENITSKY S. A.. Successful Treatment of Pulmonary Blastomycosis with Continuously Infused Amphotericin B Deoxycholate After Failure with Liposomal Amphotericin B. Annals of Pharmacotherapy [online] December, 47(6):e26-e26 [viewed 19 May 2014] Available from: doi:10.1345/aph.1R703
  3. LI RK, CIBLAK MA, NORDOFF N, PASARELL L, WARNOCK DW, MCGINNIS MR. In vitro activities of voriconazole, itraconazole, and amphotericin B against Blastomyces dermatitidis, Coccidioides immitis, and Histoplasma capsulatum. Antimicrob Agents Chemother [online] 2000 Jun, 44(6):1734-6 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10817743
  4. DANIEL L, SALIT IE. Blastomycosis during pregnancy. Can Med Assoc J [online] 1984 Oct 1, 131(7):759-61 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6478365
  5. DEAN J. L., WOLF J. E., RANZINI A. C., LAUGHLIN M. A.. Use of Amphotericin B During Pregnancy: Case Report and Review. Clinical Infectious Diseases [online] 1994 March, 18(3):364-368 [viewed 19 May 2014] Available from: doi:10.1093/clinids/18.3.364
  6. BRADSHER ROBERT. Pulmonary Blastomycosis. Semin Respir Crit Care Med [online] 2008 April, 29(2):174-181 [viewed 19 May 2014] Available from: doi:10.1055/s-2008-1063856
  7. SCHUTZE GE, HICKERSON SL, FORTIN EM, SCHELLHASE DE, DARVILLE T, GUBBINS PO, JACOBS RF. Blastomycosis in children. Clin Infect Dis [online] 1996 Mar, 22(3):496-502 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8852969
  8. RALPH E. D., PLAXTON W. R., SHARPE M. D.. Treatment of Severe Pulmonary Blastomycosis with Oral Itraconazole: Case Report. Clinical Infectious Diseases [online] 1999 November, 29(5):1336-1337 [viewed 19 May 2014] Available from: doi:10.1086/313459