Case Study: A Curious Case of Arthralgias by Poonam Mawani
A 29-year-old male presents with 8 weeks of joint pains affecting bilateral knees, ankles, and wrists, with worsening knee pain causing difficulty in ambulation. No significant past medical history, but the patient is a competitive axe thrower from Canada with occasional marijuana use. Initial differential diagnosis considered disseminated blastomycosis, confirmed by skin biopsy and fungal cultures. The patient was promptly started on liposomal amphotericin for treatment. Blastomycosis, caused by Blastomyces dermatitidis, can present challenging diagnostic scenarios in both immunocompetent and immunocompromised individuals.
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Presentation Transcript
A Curious Case of Arthralgias By Poonam Mawani Rheumatology Fellow PGY4 Olive-View UCLA
Chief Complaint 29 year old male presents with 8 weeks of joints pains
Case Presentation Pain ongoing for the last 8 weeks in bilateral knees, ankles, and wrists Pain progressively worse in bilateral knees, ankles patient presented to ED with difficulty ambulating ROS largely negative, only mentions he s also had new acne spots on his face in the same time period
Other Hx Pmhx: non contributory Social hx: competitive axe thrower born in Canada occasionally smokes marijuana, no vaping, no smoking cigarettes, no other illicit drug use occasional alcohol use no other medications No new sexual partners in the last 1 year no recent travel exposures
Hospital Course Given the subacute involvement of multiple organs, a disseminated atypical infectious process was suspected early with Blastomyces of concern given the patient s origin. Skin punch biopsy of the right wrist staining with GMS and PAS-D revealed spherical double-contoured fungal yeast with broad based buds in multinucleated giant cells, with dermal granulomatous inflammation and micro-abscesses consistent with blastomycosis. The patient was started on liposomal amphotericin within 72 hours of presentation given concern for CNS involvement. Fungal cultures from both the draining flank abscess and right wrist skin biopsy grew Blastomycosis dermatitidis identified via DNA probe on day 17 confirming the diagnosis of disseminated blastomycosis.
Blastomycosis A thermally dimorphic fungi, Blastomyces dermatitidis can present with a wide range of clinical manifestations in both immunocompetent and immunocompromised patients making diagnosis challenging. Initial infection is thought to occur due to inhalation of conidia from wet soil or organic matter with subsequent proliferation of the yeast form in alveoli followed by lymphohematogenous spread most commonly to the skin, bones and male genitourinary system. The typical profile consists of a middle aged male who participates in outdoor recreational or occupational activities.
Learning Points Blastomycosis can be difficult to diagnose Early acquisition of tissue with multi-specialty work up with rheumatology, infectious disease, pathology, and microbiology enabled early identification of fungal yeast elements which, combined with a consistent clinical history and epidemiology, led to a diagnosis of Blastomyces dermatitidis Early identification of the offending pathogen enabled rapid appropriate antimicrobial therapy preventing further morbidity in this immunocompetent patient
Take Away Points A good clinical history with identification of risk factors and exposures and proper use of epidemiological data can help focus and prioritize diagnostic studies Blastomyces dermatitidis can present with a wide variety of pulmonary, cutaneous, and osseous findings which may mimic other fungal, malignant, or autoimmune diseases.
