Thread by @WuidQ

#idgrandrounds
1/2
68/M +progressive L facial/arm numbness & weakness, R hip pain x 6 wks. +malaise/wt loss but no fever. Exam: no rashes, +dysarthria. Labs: U/R.

Brain MRI: 2x2 cm R thalamic mass w/ vaso edema
CT: speculated RUL mass, sclerotic R iliac crest/SI joint

👇

2/2
Lives in rural IL near a creek. Stays at home w/ a dog. Loves to garden. No travel, incarceration.

Neurosurgery performed burr hole/biopsy of mass (c/f glioblastoma). ID was consulted when biopsy came out.

What is your ddx/dx? @TxID_Edu @jdcooperid @GermHunterMD

1/11 Biopsy of brain mass: broad-based budding yeast, Cx: Blastomyces dermatitidis. Urine Histo Ag: low positive

CASE RESOLUTION: Disseminated blastomycosis

@LemuelNonMD @TxID_Edu @Cortes_Penfield @KartikAcharyaID @IDdoc_Vetri @jdcooperid got the correct Dx/Ddx! Thank you.

2/11 When we hear a patient w/ co-occurrence of lung-brain infection, Nocardia seems to be the #1 thought (at least on google search).

But the Ddx is actually very broad as some of you have pointed out. The table 👇 summarizes some of the Ddx.

3/11 Incidental finding of an infection on a biopsy specimen in a patient suspected of having malignancy is NOT unique to blastomycosis. True for many other fungal, mycobacterial, or even parasitic infections [#spacedlearning Check out case of Dirofilaria 👇]

https://twitter.com/WuidQ/status/1073731289751138305

4/11 But misdiagnosis of lung cancer is particularly common in pulmonary blastomycosis.

▪️Mass-like lesion, 2nd most common after alveolar infiltrates
▪️Lung mass resection in 55% of cases bit.ly/2R5yAu5

Blasto also mistaken for skin, brain, & laryngeal cancer.

5/11 Occurrence of lung-brain-BONE infection is also not unique to blastomycosis. Note however:

▪️Lung > skin > bone: top 3 most common sites of infection for both blastomycosis and coccidioidomycosis

Pathology & culture will ultimately provide dx.

6/11 The endemic mycoses are difficult to distinguish clinically from each other, especially in regions where there is geographic overlap. But some notable features:

▪️Blasto: pseudoepitheliomatous hyperplasia (verrucous skin lesions), GU involvement (4th common SSX, prostatits)

7/11 Also:

▪️Cocci: solitary peripheral thin-walled cavity, peripheral eosinophilia, skin predilection to the nasolabial fold

▪️Histo: oral ulcers very common in disseminated disease

8/11 In summary:

▪️Keep blasto (& a lot of other infections) as ddx for lesions that appear malignant clinically/imaging
▪️Lung, skin, bone, GU: most common SSX of blasto

9/11 #spacedlearning #retrieval Time to review other tweetorials of topics we’ve talked about in this thread.

Disseminated blasto (p/w skin-brain infections) 👇

https://twitter.com/WuidQ/status/1030787151968067585

10/11 Cerebral mucormycosis in PWID 👇

https://twitter.com/WuidQ/status/1197988056122449922

11/11 Lemierre syndrome w/ septic brain embolization 👇

https://twitter.com/WuidQ/status/1060304207411138561