The patient is a 20+ – year-old female of Mexican descent with a 3-month history of an eruption on her nose. She developed a painful oozing pruritic crusted plaque studded with pustules and papules. She initially declined a biopsy and was treated with doxycycline, trimethoprim-sulfamethoxazole, topical mupirocin ointment, triamcinolone, prednisone, soolantra, and clindamycin gel. Throughout this course of treatment, she had improvement in her inflammation and pustules, but no complete resolution. Her history included last traveling to Mexico about a year prior. She denies gardening, cleaning out a basement, attic, or garage. No symptoms in baby daughter or boyfriend. Her boyfriend works doing lawn care and reports showering when he gets home. He has no skin eruptions or other symptoms, including cough. The patient reports being sick six months prior with upper respiratory symptoms, that diagnosis and treatment remain unclear. She denies having a chest x-ray at that time.
What could be the cause of her eruption?
DIAGNOSIS & CASE SUMMARY:
North American Blastomycosis (Blastomyces Dermatitidis).
Blastomycosis usually is found in moist soil or decomposing wood or leaves. In the U.S., the Midwest (as well as South Central states) especially the Great Lakes and Ohio and Mississippi river valleys are a great source for this fungus. There have been outbreaks over the years in Wisconsin usually related to groups camping or boating on moist soil, leaves or branches (recently in the last few years a number of kayakers were diagnosed with Blastomycosis while landing on uninhabited islands on the Wolf river near New London). Compromised immune systems or susceptible individuals can get respiratory or cutaneous Blastomycosis. Urine or Blood tests as well as tissue cultures can help diagnose this infections.
Patient has had an additional biopsy performed for definitive fungal culture diagnosis, however, the outside laboratory reported no growth.
The patient also had a complete workup with infectious disease to evaluate for systemic disease. She was treated with itraconazole with complete resolution. We do not have a follow up photo as the patient did not follow up with dermatology.