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Blastomycosis in Patients with the Acquired Immunodeficiency Syndrome

Peter G. Pappas, MD; John C. Pottage, MD; William G. Powderly, MD; Victoria J. Fraser, MD; Charles W. Stratton, MD; Stacey McKenzie, MD; Tapper Michael L., MD; Herman Chmel, MD; Frank C. Bonebrake, MD; Raymond Blum, MD; Robert W. Shafer, MD; Coleman King, MD; and William E. Dismukes, MD
[+] Article, Author, and Disclosure Information

This material was presented as an abstract at the Thirtieth Interscience Conference on Antimicrobial Agents and Chemotherapy, Atlanta, Georgia, October 1990 (abstract 1166).

Grant Support: By National Institute of Allergy and Infectious Diseases contract N01-AI-15082.

Requests for Reprints: Peter G. Pappas, MD, University of Alabama at Birmingham, Division of Infectious Diseases, 229 Tinsley Harrison Tower, University Station, Birmingham, AL 35294-0006.

Current Author Addresses: Drs. Pappas and Dismukes: University of Alabama at Birmingham, Division of Infectious Diseases, 229 Tinsley Harrison Tower, University Station, Birmingham, AL 35294-0006. Dr. Pottage: Rush-Presbyterian-St. Lukes Medical Center, Section of Infectious Diseases, 1740 West Harrison, Room 140-143 Academic Facility, Chicago, IL 60612.

Drs. Powderly and Fraser: Washington University Medical Center, Infectious Diseases Section, 4511 Forest Park, Suite 304, St. Louis, MO 63110.

Drs. Stratton and McKenzie: Vanderbilt University Medical Center, Department of Pathology, C3321 MCN, Nashville, TN 37232.

Dr. Tapper: Lenox Hill Hospital, 100 East 77th Street, New York City, NY 10021.

Dr. Chmel: St. Francis Medical Center, 601 Hamilton Avenue, Trenton, NJ 08629.

Dr. Bonebrake: Dean Medical Center, 1313 Fish Hatchery Road, Madison, WI 53715.

Dr. Blum: University of Colorado Medical Center, 4200 B-168, Denver, CO 80262.

Dr. Shafer: Division of Infectious Diseases, SUMC, Stanford, CA 94305.

Dr. King: Medical Center Clinic, 8333 N. David Highway, Pensacola, FL 32514.

© 1992 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1992;116(10):847-853. doi:10.7326/0003-4819-116-10-847
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Objective: To describe the clinical, demographic, radiographic, diagnostic, and therapeutic aspects of blastomycosis in patients with the acquired immunodeficiency syndrome (AIDS).

Design: A retrospective survey.

Setting: Ten university medical centers and community hospitals, six in geographic areas endemic for Blastomyces dermatitidis, and four outside the endemic area.

Patients: We identified 15 patients with blastomycosis and positive serologic test results for human immunodeficiency virus (HIV).

Measurements: A diagnosis of blastomycosis was based on a positive culture (14 patients) or typical histopathologic features (one patient) for B. dermatitidis in clinical specimens.

Results: Twelve of 15 patients had a previous or concomitant AIDS-defining illness at the time of diagnosis of blastomycosis, and only one patient had a CD4 lymphocyte count of greater than 200 cells/mm3. Two patterns of disease emerged: localized pulmonary involvement (seven patients), and disseminated or extrapulmonary blastomycosis (eight patients). Central nervous system involvement was common (40%). Six patients died within 21 days of presentation with blastomycosis, including four patients with disseminated and two with fulminant pulmonary disease. Among the nine patients who survived longer than 1 month, all received amphotericin B as initial antifungal therapy, and most received subsequent therapy with ketoconazole. Only two of these nine patients died with evidence of progressive blastomycosis.

Conclusions: Blastomycosis is a late and frequently fatal infectious complication in a few patients with AIDS. In these patients, overwhelming disseminated disease including involvement of the central nervous system is common, and it is associated with a high early mortality. Initial therapy with amphotericin B is appropriate in patients with AIDS and presumptive blastomycosis.





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