5-59
No Improvement/Deterioration: Further evaluation is necessary if infection does not resolve within two
weeks.
Follow-up Actions
Return evaluation: If lesions do not resolve consider alternate treatment.
Evacuation/Consultation Criteria: Evacuation is not required for most patients. However, those with
recurrent thrush, disseminated infection or who require intravenous amphotericin B therapy should be referred
to the appropriate higher echelon of care.
NOTE: Oral candidiasis (thrush) in a young adult should always raise the suspicion of immunocompromise,
especially undiagnosed HIV infection.
ID: Blastomycosis
(North American Blastomycosis, Gilchrist Disease)
LTC Duane Hospenthal, MC, USAIntroduction: Blastomyces dermatitidis is a yeast-like fungus that causes a spectrum of disease including
asymptomatic infection, acute and chronic pulmonary infection and disseminated infection of the skin, bone,
GU tract, and rarely, the CNS. This infection is seen most often in central and southeast US in areas near
rivers or streams. Approximately 1/2 of exposed persons will develop symptomatic disease. The incubation
period is 30-45 days. Most individuals seeking care for this infection have progressive pulmonary disease
or cutaneous lesions.
Subjective: Symptoms
Acute pulmonary infection produces fever, cough, and pleuritic chest pain. Chronic pulmonary disease
presents with similar symptoms over a longer course. Skin lesions are typically painless or slightly tender.
Focused History: Have you had any recent travel/exposure to rivers or streams in the central or southeast
US? (endemic area)
Objective: Signs
Pulmonary infection is associated with diffuse auscultatory findings and fever. Chronic pulmonary disease can
also include hemoptysis, weight loss, and skin lesions. Skin lesions are most often located on the face, scalp,
neck, and extremities. These begin as red papules or nodules that enlarge and then ulcerate or become
verrucous. Associated adenopathy is uncommon.
Using Advanced Tools: Lab: Large (8-15 mm), thick-walled, broad-based, budding yeast cells may be
visible on Gram stain of sputum or lesion.
Assessment:
Differential Diagnosis
Acute pulmonary infection - influenza, bacterial pneumonia
Chronic pulmonary infection - tuberculosis, lung cancer, other fungal pneumonias
Skin lesions - squamous cell carcinoma, mycosis fungoides
Plan:
Treatment
Primary: IV amphotericin B is required in life-threatening infections, all central nervous system infections,
infections in immunocompromised patients and in pregnant patients. SOF medics should not administer this
toxic agent in the field. Itraconazole can be used in all other infections at a dose of 200-400 mg/day po,