DOI: 10.1148/rg.273065122
Imaging Manifestations of Blastomycosis: A Pulmonary Infection with Potential Dissemination1
Wayne Fang, MD,
Lacey Washington, MD, and
Nidhi Kumar, MD
1 From the Departments of Radiology (W.F.) and Pathology (N.K.), Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226; and the Department of Radiology, Duke University Medical Center, Durham, NC (L.W.). Presented as an education exhibit at the 2005 RSNA Annual Meeting. Received June 21, 2006; revision requested August 9 and received September 22; accepted September 29. All authors have no financial relationships to disclose.
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Figure 1a. B dermatitidis. (a) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows a typical round B dermatitidis yeast cell (arrow) with a thick double refractile cell wall and surrounded by granulomatous tissue. (b) Photomicrograph (original magnification, x100; Gomori methenamine silver stain) shows reproducing B dermatitidis cells, which are characterized by broad-based budding and large daughter cells that are nearly as large as the mother cell before separation.
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Figure 1b. B dermatitidis. (a) Photomicrograph (original magnification, x100; hematoxylin-eosin stain) shows a typical round B dermatitidis yeast cell (arrow) with a thick double refractile cell wall and surrounded by granulomatous tissue. (b) Photomicrograph (original magnification, x100; Gomori methenamine silver stain) shows reproducing B dermatitidis cells, which are characterized by broad-based budding and large daughter cells that are nearly as large as the mother cell before separation.
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Figure 2. Satellite map illustrates the endemic regions of North American blastomycosis (brown), defined as areas of high disease prevalence: the Ohio and Mississippi River valleys, the St Lawrence River area, the Great Lakes region, and part of central Canada. (Courtesy of the National Aeronautics and Space Administration, The Visible Earth [http://visibleearth.nasa.gov].)
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Figure 3. Airspace consolidation from blastomycosis in a young boy with acute fever and productive cough. Anteroposterior chest radiograph shows a large confluent left upper lobar–lingular consolidation obscuring the left border of the heart. Air bronchograms can be seen faintly.
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Figure 4. Airspace consolidation from blastomycosis in a different patient. Computed tomographic (CT) scan shows a large confluent area of consolidation with prominent air bronchograms.
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Figure 5a. Airspace consolidation from blastomycosis in a 45-year-old woman with persistent chronic cough. (a) Chest radiograph shows patchy consolidation in the retrocardiac region. Patchy consolidation is the most common finding in blastomycosis. (b) Magnified view more clearly shows the patchy infiltrate. (c) CT scan shows irregular consolidation in the left lower lobe.
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Figure 5b. Airspace consolidation from blastomycosis in a 45-year-old woman with persistent chronic cough. (a) Chest radiograph shows patchy consolidation in the retrocardiac region. Patchy consolidation is the most common finding in blastomycosis. (b) Magnified view more clearly shows the patchy infiltrate. (c) CT scan shows irregular consolidation in the left lower lobe.
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Figure 5c. Airspace consolidation from blastomycosis in a 45-year-old woman with persistent chronic cough. (a) Chest radiograph shows patchy consolidation in the retrocardiac region. Patchy consolidation is the most common finding in blastomycosis. (b) Magnified view more clearly shows the patchy infiltrate. (c) CT scan shows irregular consolidation in the left lower lobe.
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Figure 6a. Airspace consolidation from blastomycosis in a 20-year-old man. Anteroposterior (a) and lateral (b) chest radiographs show right middle and lower lobar consolidation, an uncommon manifestation of blastomycosis. Patchy consolidation is also seen in the right upper lobe.
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Figure 6b. Airspace consolidation from blastomycosis in a 20-year-old man. Anteroposterior (a) and lateral (b) chest radiographs show right middle and lower lobar consolidation, an uncommon manifestation of blastomycosis. Patchy consolidation is also seen in the right upper lobe.
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Figure 7a. Airspace consolidation from blastomycosis in a 26-year-old man who presented with right lower lobar consolidation after several months of treatment with antibiotics. CT scan (a) and coronal reformatted image (b) show round low-attenuation lesions that are suggestive of small cavities. The patient also developed extensive cutaneous lesions.
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Figure 7b. Airspace consolidation from blastomycosis in a 26-year-old man who presented with right lower lobar consolidation after several months of treatment with antibiotics. CT scan (a) and coronal reformatted image (b) show round low-attenuation lesions that are suggestive of small cavities. The patient also developed extensive cutaneous lesions.
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Figure 8. Fulminant blastomycosis in a 48-year-old immunocompetent man with fever, cough, and dyspnea. Radiograph shows bilateral diffuse areas of alveolar consolidation, which developed rapidly and required intubation after 2 days of hospitalization. The patient died 10 days later.
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Figure 9a. Blastomycotic mass in a 51-year-old male heavy smoker who was referred by a community clinic. (a) Chest radiograph shows a mass in the left upper lobe. (b) Corresponding CT scan shows the mass to be well circumscribed and round with irregular borders. The results of CT-guided biopsy were inconclusive, and the patient underwent left upper lobectomy and mediastinal lymph node dissection for suspected lung carcinoma. Blastomycosis was diagnosed.
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Figure 9b. Blastomycotic mass in a 51-year-old male heavy smoker who was referred by a community clinic. (a) Chest radiograph shows a mass in the left upper lobe. (b) Corresponding CT scan shows the mass to be well circumscribed and round with irregular borders. The results of CT-guided biopsy were inconclusive, and the patient underwent left upper lobectomy and mediastinal lymph node dissection for suspected lung carcinoma. Blastomycosis was diagnosed.
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Figure 10. Intermediate-sized nodules from blastomycosis in a 44-year-old man who presented with pneumonialike symptoms. Early chest radiograph shows bilateral diffuse intermediate-sized nodules along with patchy consolidations at the lung bases. The disease progressed to a fulminant course, requiring many days of ventilator support for the patient.
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Figure 11. Intermediate-sized nodules from blastomycosis in a 40-year-old woman with persistent cough, chest pain, and intermittent fevers. The patient had experienced progression of symptoms over several months. CT scan shows multiple bilateral intermediate-sized nodules. A large cavitary lesion (not shown) was also present in the right middle lobe.
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Figure 12a. (a) Reticulonodular pattern in blastomycosis. Radiograph shows bilateral reticulonodular opacities, with a large cavitary lesion in the right upper lobe. (b) Magnified view more clearly depicts the interstitial opacities in the right lower lung. (c) On a CT scan, the reticulonodular opacities seen in a have a tree-in-bud appearance.
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Figure 12b. (a) Reticulonodular pattern in blastomycosis. Radiograph shows bilateral reticulonodular opacities, with a large cavitary lesion in the right upper lobe. (b) Magnified view more clearly depicts the interstitial opacities in the right lower lung. (c) On a CT scan, the reticulonodular opacities seen in a have a tree-in-bud appearance.
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Figure 12c. (a) Reticulonodular pattern in blastomycosis. Radiograph shows bilateral reticulonodular opacities, with a large cavitary lesion in the right upper lobe. (b) Magnified view more clearly depicts the interstitial opacities in the right lower lung. (c) On a CT scan, the reticulonodular opacities seen in a have a tree-in-bud appearance.
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Figure 13. Fibrotic interstitial changes in a 49-year-old woman with chronic dry cough. CT scan demonstrates fibrotic interstitial changes in the left upper lobe. Biopsy of a skin lesion on the right cheek revealed blastomycosis.
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Figure 14a. Miliary blastomycosis in an acutely ill patient, who also had dissemination to the sacrum and a phalanx of the hand. (a, b) Posteroanterior (a) and lateral (b) chest radiographs demonstrate bilateral diffuse miliary changes. (c) CT scan shows innumerable tiny nodules with a random distribution in both lungs.
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Figure 14b. Miliary blastomycosis in an acutely ill patient, who also had dissemination to the sacrum and a phalanx of the hand. (a, b) Posteroanterior (a) and lateral (b) chest radiographs demonstrate bilateral diffuse miliary changes. (c) CT scan shows innumerable tiny nodules with a random distribution in both lungs.
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Figure 14c. Miliary blastomycosis in an acutely ill patient, who also had dissemination to the sacrum and a phalanx of the hand. (a, b) Posteroanterior (a) and lateral (b) chest radiographs demonstrate bilateral diffuse miliary changes. (c) CT scan shows innumerable tiny nodules with a random distribution in both lungs.
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Figure 17. Cavitary blastomycotic lesion in a 29-year-old man with a 3–4-week history of fever, chills, dyspnea, and productive cough. CT scan shows a large, apical, thick-walled cavitary lesion. Cavitary lesions can be found in both acutely ill and asymptomatic patients.
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Figure 21a. Osseous involvement by blastomycosis in a young adult. (a) Radiograph shows an osteolytic lesion with indistinct margins in the middiaphysis of the humerus. (b) Magnified view more clearly delineates the lesion and its margins. (c) Radiograph shows an osteolytic lesion in the distal metaphysis of the ulna that crosses the physis. Solid uninterrupted periosteal reaction is evident along the lateral ulna. (d) On a bone scintigram, both lesions show increased radiotracer uptake.
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Figure 21b. Osseous involvement by blastomycosis in a young adult. (a) Radiograph shows an osteolytic lesion with indistinct margins in the middiaphysis of the humerus. (b) Magnified view more clearly delineates the lesion and its margins. (c) Radiograph shows an osteolytic lesion in the distal metaphysis of the ulna that crosses the physis. Solid uninterrupted periosteal reaction is evident along the lateral ulna. (d) On a bone scintigram, both lesions show increased radiotracer uptake.
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Figure 21c. Osseous involvement by blastomycosis in a young adult. (a) Radiograph shows an osteolytic lesion with indistinct margins in the middiaphysis of the humerus. (b) Magnified view more clearly delineates the lesion and its margins. (c) Radiograph shows an osteolytic lesion in the distal metaphysis of the ulna that crosses the physis. Solid uninterrupted periosteal reaction is evident along the lateral ulna. (d) On a bone scintigram, both lesions show increased radiotracer uptake.
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Figure 21d. Osseous involvement by blastomycosis in a young adult. (a) Radiograph shows an osteolytic lesion with indistinct margins in the middiaphysis of the humerus. (b) Magnified view more clearly delineates the lesion and its margins. (c) Radiograph shows an osteolytic lesion in the distal metaphysis of the ulna that crosses the physis. Solid uninterrupted periosteal reaction is evident along the lateral ulna. (d) On a bone scintigram, both lesions show increased radiotracer uptake.
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Figure 22. CT scan shows B dermatitidis of the pelvis involving the sacroiliac joint and the surrounding bone on both sides of the joint. The lesion is permeative with indistinct margins. Cortical destruction is also seen.
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Figure 24a. Blastomycosis in a 26-year-old man with chronic cough who developed a headache. Two weeks earlier, skin lesions that the patient thought were acne had appeared on his face, later spreading to the upper body. Axial fluid-attenuated inversion recovery (a) and coronal gadolinium-enhanced fat-saturated (b) MR images show multiple enhancing high-signal-intensity T2 lesions. Blastomycosis was found in sputum, urine, and skin lesion samples.
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Figure 24b. Blastomycosis in a 26-year-old man with chronic cough who developed a headache. Two weeks earlier, skin lesions that the patient thought were acne had appeared on his face, later spreading to the upper body. Axial fluid-attenuated inversion recovery (a) and coronal gadolinium-enhanced fat-saturated (b) MR images show multiple enhancing high-signal-intensity T2 lesions. Blastomycosis was found in sputum, urine, and skin lesion samples.
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Copyright © 2007 by the Radiological Society of North America.
