Blastomycosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Vidit Bhargava, M.B.B.S [2] Aditya Ganti M.B.B.S. [3]

Overview

Blastomycosis have overlapping signs & symptoms with that of other fungal and bacterial disorders. A detailed History, Physical examination and serological tests helps us to pin-point the diagnosis. All this disorders can be often misinterpreted as community acquired pneumonia as they all present with similar complaints such as fever, productive cough, chest pain and shortness of breath. The following table elaborates differentiating features between blastomycosis from other fungal disorders.

Fungal

• Coccidioidomycosis
• Histoplasmosis
• Aspergillosis
• Pneumocystis pneumonia
• Sporotrichosis

Disease	Geographic distribution	High risk Groups	Differentiating Features	Microscopic findings	Differentiating Laboratory findings
Histoplasmosis	Mississippi and Ohio River valleys	Cave dwellers Soil that contains bird or bat dropping	Palate and oral ulcers Spleenomegaly	Yeast are typically smaller, with narrow-based budding, found intracellularly within macrophages	Pancytopenia Urine antigen testing
Coccidioidomycosis	Southwestern US region	Opportunistic infection seen in AIDS	Rash on upper body or legs Night sweats	Characteristic spherule appearance	Serologic tests( enzyme immune assay )more sensitive
Paracoccidioidomycosis	Central and South america	Opportunistic infection seen in AIDS	Lymphadenopathy Hepatosplenomegaly Bone marrow dysfunction	Smaller fungi with thin cell walls, forming mariner wheel appearance, circumferentially surrounding the parent cell.( Captain wheel appearance )	Elevated liver enzymes Hyperbilirubinemia Hypoalbuminemia
Sporotrichosis	Ubiquitous	Gardeners	Person’s hand or the arm Lymphadenitis (nodular)	Finger or cigar shaped yeast.	Sporotrichin skin test
Aspergillosis	Ubiquitous	Cystic fibrosis or asthma. tuberculosis. Immunocomprimised	Wheezing Stuffiness, runny nose Hemoptysis Weight loss	Septated hyphae with acute angle branching	Cell wall detection using galactomannan antigen detection, Beta-D-glucan detection test.
Pulmonary Tuberculosis			No cutaneous involvement	Acid fast bacteria
Nocardiosis			Immunocompromised people worldwide distribution		Microscopic examination ; thin, branching gram-positive bacilli acid fast positive

Bacterial

• Anthrax
• Legionella
• Listeriosis
• Brucellosis
• Tuberculosis
• Scrub typhus
• Leptospirosis
• Cat scratch fever

Viral

• Chickenpox
• Herpes(Prodrome)
• Influenza
• Parainfluenza
• HIV -1/-2
• Coxsackie B virus
• Hepatits
• Cytomegalovirus
• Eastern equine encephalitis virus
• Venezuelan equine encephalitis
• Coronavirus
• California Encephalitis virus

Chronic and disseminated disease

Chronic blastomycosis may be initially confused with a malignancy or tuberculosis. While spread to other areas may be confused with malignancy as well. Skin lesions are often misdiagnosed as pyoderma gangreosum or keratoacanthoma. Therefore, a high index of suspicion is needed on the part of physician to diagnose blastomycosis