Original Article

Blastomycosis of Bones and Joints

Authors: Mark Oppenheimer, BSc, John M. Embil, MD, FRCPC, Brian Black, MD, FRCSC, Lyle Wiebe, CPHI(C), Bill Limerick, CPHI(C), Kerry MacDonald, MD, Elly Trepman, MD

Abstract

A retrospective study of 45 patients hospitalized with blastomycosis of bones or joints revealed 41 cases of osteomyelitis and 12 cases of septic arthritis. The majority were men (35 [78%] patients) and non-Aboriginal (32 [71%] patients). Median time from the onset of symptoms to hospitalization was shorter in women than men (male, 48 d; female, 14 d; P < 0.02), and shorter for Aboriginals than non-Aboriginals (non-Aboriginal, 50 d; Aboriginal, 19 d;P < 0.04). Cutaneous disease was present in 33 (73%) patients, and lung involvement was present in 29 (64%) patients. The most common osseous sites of involvement were the lower limb and axial skeleton. Common orthopaedic symptoms of bone lesions included bone pain in 42 (78%) patients, swelling in 32 (59%) patients, and soft tissue abscesses in 21 (39%) patients. Joint infection (12 patients) manifested as a monoarticular arthropathy presenting with effusion in 9 (75%) patients, pain in 8 (67%) patients, and decreased range of motion in 5 (42%) patients. Osseous blastomycosis can mimic bacterial infection and should be included in the differential diagnosis of bone and joint infection in patients who have visited or who live in geographic regions where B dermatitidis is endemic.


Key Points


* A retrospective study of 45 patients hospitalized with blastomycosis of bones or joints revealed 41 cases of osteomyelitis and 12 cases of septic arthritis.


* Cutaneous disease was present in 33 (73%) patients and lung involvement was present in 29 (64%) patients.


* The most common osseous sites of involvement were the lower limb and axial skeleton.


* Joint infection manifested as a monoarticular arthropathy presenting with effusion, pain, and decreased range of motion.


* Osseous blastomycosis can mimic bacterial infection and should be included in the differential diagnosis of bone and joint infection in patients who have visited or who live in geographic regions where B dermatitidis is endemic.

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References

1. Crampton TL, Light RB, Berg GM, et al. Epidemiology and clinical spectrum of blastomycosis diagnosed at Manitoba hospitals. Clin Infect Dis 2002;34:1310–1316.
 
2. Furcolow ML, Balows A, Menges RW, et al. Blastomycosis: an important medical problem in the Central United States. JAMA 1966;198:529–532.
 
3. Schwarz J, Baum GL. Blastomycosis. Am J Clin Pathol 1951;21:999–1029.
 
4. Riegler HF, Goldstein LA, Betts RF. Blastomycosis osteomyelitis. Clin Orthop Relat Res 1974;100:225–231.
 
5. Chapman SW. Blastomyces dermatitidis. Bennett's Principles and Practice of Infectious Diseases. 6th edition. Mandell GL, Bennett JE, Dolin R, (eds). Philadelphia, Elsevier, 2005, pp 3026–3040.
 
6. Cherniss EI, Waisbren BA. North American blastomycosis: a clinical study of 40 cases. Ann Intern Med 1956;44:105–123.
 
7. MacDonald PB, Black GB, MacKenzie R. Orthopaedic manifestations of blastomycosis. J Bone Joint Surg Am 1990;72:860–864.
 
8. Chapman SW, Lin AC, Hendricks KA, et al. Endemic blastomycosis in Mississippi: epidemiological and clinical studies. Semin Respir Infect 1997;12:219–228.
 
9. Saiz P, Gitelis S, Virkus W, et al. Blastomycosis of long bones. Clin Orthop Relat Res2004;421:255–259.
 
10. Jones RR, Martin DS. Blastomycosis of bone. Surgery 1941;10:931–938.
 
11. Bassett FH, Tindall JP. Blastomycosis of bone. South Med J 1972;65:547–555.
 
12. Colonna PC, Gucker T. Blastomycosis of the skeletal system. J Bone Joint Surg 1944;26:322–328.
 
13. Albert MC, Zachary SV, Alter S. Blastomycosis of the forearm synovium in a child. Clin Orthop Relat Res 1995;317:223–226.
 
14. International Classification of Diseases, 9th Revision. Clinical Modification, 4th ed. Los Angeles, Practice Management Information Corporation (PMIC), 1994.
 
15. Cherneski C, Bartley D, Al-Thaquafi H, et al. Infection with Blastomyces dermatitidis in a Saudi Arabian man. Am J Orthop, in press.
 
16. Embil JM, Wiens JL, Oppenheimer M, et al. Foot ulcer and osteomyelitis. CMAJ 2006;174:35–36.
 
17. Embil JM, Aoki FY, Hershfield ES, et al. Respiratory failure in a man with bone and lung lesions. Hosp Pract (Minneap) 1998;33:211–219.
 
18. Centers for Disease Control and Prevention (CDC). Blastomycosis - Wisconsin, 1986–1995. MMWR Morb Mortal Wkly Rep 1996;45:601–603.
 
19. Royal Commission on Aboriginal Peoples. Report of the Royal Commission on Aboriginal Peoples. Volume 1. Looking Forward, Looking Back. Ottawa: Canada Communication Group, 1996.
 
20. Statistics Canada. Census of Population, May 15, 2001. Available at http://www12.statcanca. Accessed May 22, 2004.
 
21. Kepron MW, Schoemperlen CB, Hershfield ES, et al. North American blastomycosis in Central Canada. Can Med Assoc J 1972;106:243–246.
 
22. Lowry PW, Kelso KY, McFarland LM. Blastomycosis in Washington Parish, Louisiana, 1976–1985. Am J Epidemiol 1989;130:151–159.
 
23. Trovato F. Aboriginal mortality in Canada, the United States and New Zealand. J Biosoc Sci 2001;33:67–86.
 
24. Larcombe L, Rempel JD, Dembinski I, et al. Differential cytokine genotype frequencies among Canadian Aboriginal and Caucasian populations. Genes Immun 2005;6:140–144.
 
25. Statistics Canada. Percentage of smokers in the population, by province, 2000–2001. Available at http://www40statcanca/101/cst01/health07b.htm. Accessed February 3, 2005.
 
26. Davies SF, Sarosi GA. Epidemiological and clinical features of pulmonary blastomycosis. Semin Respir Infect 1997;12:206–218.
 
27. Vaaler AK, Bradsher RW, Davies SF. Evidence of subclinical blastomycosis in forestry workers in northern Minnesota and northern Wisconsin. Am J Med 1990;89:470–476.
 
28. Stelling CB, Woodring JH, Rehm SR, et al. Miliary pulmonary blastomycosis. Radiology 1984;150:7–13.
 
29. Sarosi GA, Davies SF. Blastomycosis. Am Rev Respir Dis 1979;120:911–938.
 
30. Laskey W, Sarosi GA. Endogenous activation in blastomycosis. Ann Intern Med 1978;88:50–52.
 
31. Landis FB, Varkey B. Late relapse of pulmonary blastomycosis after adequate treatment with amphotericin B. Am Rev Respir Dis 1976;113:77–81.
 
32. Ehni W. Endogenous reactivation in blastomycosis. Am J Med 1989;86:831–832.
 
33. Sanders LL. Blastomycosis arthritis. Arthritis Rheum 1967;10:91–98.
 
34. Bayer AS, Scott VJ, Guze LB. Fungal arthritis, IV: blastomycotic arthritis. Semin Arthritis Rheum 1979;9:145–151.
 
35. Claflin K, Milbauer J, Sullivan B. Ketoconazole and blastomycotic osteomyelitis. Ann Intern Med 1983;98:260–261.
 
36. Gehweiler JA, Capp MP, Chick EW. Observations on the roentgen patterns in blastomycosis of bone: a review of cases from the Blastomycosis Cooperative Study of the Veterans Administration and Duke University Medical Center. Am J Roentgenol Radium Ther Nucl Med 1970;108:497–510.
 
37. Kalbhen C. Blastomycotic osteomyelitis. Orthopedics 1991;14:722–728.
 
38. Detrisac DA, Harding WG, Greiner AL, et al. Vertebral North American blastomycosis. Surg Neurol 1980;13:311–312.
 
39. Guler N, Palanduz A, Ones U, et al. Progressive vertebral blastomycosis mimicking tuberculosis. Pediatr Infect Dis J 1995;14:816–818.
 
40. Daniel BL, Crabbe JP, Gritters L, et al. Bone scintigraphy in blastomycotic osteomyelitis. Clin Nucl Med 1993;18:203–207.
 
41. Hershkovitz I, Rothschild BM, Dutour O, et al. Clues to recognition of fungal origin of lytic skeletal lesions. Am J Phys Anthropol 1998;106:47–60.