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SKIN LESIONS CHALLENGING THE DIAGNOSIS OF PULMONARY SARCOIDOSIS

Mercy Hospital and Medical Center, Chicago, IL

INTRODUCTION:Pulmonary Blastomycosis can mimick sarcoidosis. We describe a case of pulmonary Bastomycosis diagnosed as Sarcoidosis untill the appearance of skin lesions.

CASE PRESENTATION:A 54 year old Hispanic gentleman with no significant past medical history presented with 2 weeks history of productive cough, weight loss and night sweats. His chest X-ray revealed right middle lung mass like lesion. He had 30 pack year of smoking history. He had received a course of outpatient levofloxacin for possible pneumonia which failed to improve his symptoms. A computed tomography scan of the chest confirmed the 5 x 5.4 cm spiculated right middle lobe mass. A transbronchial biopsy revealed noncaseating granulomas with giant cells. Staining for bacteria, acid fast bacilli , fungi and cultures after four weeks of incubation were negative. Percutaneous biopsy of the mass had the same results. Patient was empirically started on prednisone . A repeat CT scan showed significant decrease in the size of the mass, 4 weeks later. About ten weeks from the initial presentation, the patient returned with multiple, painless and scaly skin lesions with serosanguinous discharge . An excisional biopsy of the skin lesions revealed giant cells containing spores with double walled, broad-based single buds consistent with Blastomyces dermatitidis. The prednisone was tapered off and patient was started on itraconozole for disseminated blastomycosis.

DISCUSSIONS:The causative organism for bastomycosis may not survive well in clinical specimens. Immediate culture on appropriate media should be arranged when fungal infection is suspected. Most strains of Blastomyces grow within 14 days, but growth may be delayed as long as 8 weeks.

CONCLUSION:This case illustrates the potential pitfalls in the diagnosis of pulmonary blastomycosis.

DISCLOSURE:Kamran Mahmood, No Financial Disclosure Information; No Product/Research Disclosure Information