Man With Thigh Pain

Abstract

A 33-year-old construction worker with diabetes presented to an emergency department in Chicago, Illinois, with thigh pain for 1 year. Physical examination revealed a large, heme-crusted, multicolored annular plaque with central atrophy and an indurated, verrucous border involving the entire circumference of the lower right thigh (Figure). Laboratory study results were significant for a sedimentation rate of 22 mm/h and a C-reactive protein level of 2.62 mg/dL. A punch biopsy, performed during a dermatology consultation, later confirmed the diagnosis. Cutaneous blastomycosis. Blastomycosis is a systemic pyogranulomatous infection, endemic to states surrounding Mississippi and the Ohio River Valley, that occurs because of inhalation of spores from Blastomyces dermatidis or Blastomyces gilchristii. Immunocompromised patients and those with diabetes are at the highest risk for infection.1Lemos L.B. Baliga M. Guo M. et al.Acute respiratory distress syndrome and blastomycosis: presentation of nine cases and review of the literature.Ann Diagn Pathol. 2001; 5: 1-9Crossref PubMed Scopus (64) Google Scholar,2Pappas P.G. Threlkeld M.G. Bedsole G.D. et al.Blastomycosis in immunocompromised patients.Med (Baltim). 1993; 72: 311-325Crossref PubMed Scopus (149) Google Scholar Although the most common site of infection is the lungs, presenting as pneumonia, hematogenous spread and extrapulmonary manifestations are common.3Azar M.M. Massi R. Relich R.F. et al.Blastomycosis in Indiana: clinical and epidemiologic patterns of disease gleaned from a multicenter retrospective study.Chest. 2015; 148: 1276-1284Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar The skin is the second most common site of infection, mimicking squamous cell carcinoma, with bone being the third, presenting as osteomyelitis.4Oppenheimer M. John M.E. Black B. et al.Blastomycosis of bones and joints.South Med J. 2007; 100: 570-578Crossref PubMed Scopus (51) Google Scholar The final diagnosis is made by histology and culture of infected tissue. Before the advent of effective antifungals, systemic blastomycosis often progressed to acute respiratory distress syndrome with high general mortality.3Azar M.M. Massi R. Relich R.F. et al.Blastomycosis in Indiana: clinical and epidemiologic patterns of disease gleaned from a multicenter retrospective study.Chest. 2015; 148: 1276-1284Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,5Martin D.S. Smith D. Blastomycosis I: a review of the literature.Am Rev Tuberc. 1939; 39: 275Google Scholar Current treatments include amphotericin B or azole therapy. Lethal cases now most commonly occur in the setting of acute pulmonary blastomycosis and associated acute respiratory distress syndrome.1Lemos L.B. Baliga M. Guo M. et al.Acute respiratory distress syndrome and blastomycosis: presentation of nine cases and review of the literature.Ann Diagn Pathol. 2001; 5: 1-9Crossref PubMed Scopus (64) Google Scholar Our patient biopsy result confirmed pulmonary blastomycosis, likely from an occupational exposure, which improved with systemic itraconazole.