51 y.o. Man with Bilateral 51 y.o. Man with Bilateral Osteomyelitis of the Osteomyelitis of the

HandsHandsDavid Feldstein, MDDavid Feldstein, MD

PCC 5/10/06PCC 5/10/06

PatientPatient

51 y.o. man with hx of pulmonary 51 y.o. man with hx of pulmonary sarcoidosissarcoidosis– Osteomyelitis of bilateral 5Osteomyelitis of bilateral 5 thth fingers fingers

8 weeks (PTA)8 weeks (PTA)– Pain, erythema, swelling right 5Pain, erythema, swelling right 5 thth PIP joint PIP joint– No trauma, injury, fevers chillsNo trauma, injury, fevers chills– Urgent care – clinical dx fracture and Urgent care – clinical dx fracture and

splintedsplinted

PatientPatient

7 weeks (PTA)7 weeks (PTA)– Return UC increased swelling and painReturn UC increased swelling and pain– Xray with bony destruction head of 5Xray with bony destruction head of 5 thth

proximal phalynx proximal phalynx – Ceftri x 1 and started on cephalexinCeftri x 1 and started on cephalexin

4 weeks (PTA)4 weeks (PTA)– Admitted to outside hospitalAdmitted to outside hospital– Progression of sx right 5Progression of sx right 5thth finger finger – Left 5Left 5thth finger now with swelling and finger now with swelling and

erythemaerythema

PatientPatient

Outside HospitalOutside Hospital– XrayXray

»Almost complete destruction right 5Almost complete destruction right 5 thth middle phalynxmiddle phalynx

»Lucency left 5Lucency left 5thth proximal phalynx proximal phalynx– Bone scanBone scan

» Increased signal bilateral 5Increased signal bilateral 5 thth fingers and fingers and right wristright wrist

PatientPatient

Outside Hospital ManagementOutside Hospital Management– Incision and drainage right 5Incision and drainage right 5 thth finger finger– Pin placed for stabilization Pin placed for stabilization – Gram stain and cx of fluid negativeGram stain and cx of fluid negative– Vancomycin /Rifampin and dischargedVancomycin /Rifampin and discharged

No clinical improvement and worsening No clinical improvement and worsening xrays 3 weeks laterxrays 3 weeks later

Sent to UW Sent to UW (FINALLY!!)(FINALLY!!)

Why?Why?

Why did he fail treatment?Why did he fail treatment?

At UWAt UW

No constitutional sx or other skin No constitutional sx or other skin findingsfindings

PMH – SarcoidosisPMH – Sarcoidosis SH – Machinist, lives on a farmSH – Machinist, lives on a farm PEPE

– VSS, NADVSS, NAD– Lungs clearLungs clear– Skin – see photosSkin – see photos

ObjectivesObjectives

Recognize improper treatment of Recognize improper treatment of osteomyelitisosteomyelitis

Describe symptoms of blastomycosis Describe symptoms of blastomycosis infectioninfection

Describe treatment of blastomycosisDescribe treatment of blastomycosis

Blastomyces DermatitidisBlastomyces Dermatitidis

Dimorphic fungusDimorphic fungus Mycelial phase in natureMycelial phase in nature Converts to yeast at body temperatureConverts to yeast at body temperature Warm moist soil in wooded areas rich in Warm moist soil in wooded areas rich in

organic debrisorganic debris Endemic – See figureEndemic – See figure

Rippon JW. Medical Mycology: The Pathogenic Fungi and Pathogenic Actinomycetes. 3rd ed. Philadelphia: WB Saunders; 1988:474.

Incidence of Blastomycosis in North America

Clinical ManifestationsClinical Manifestations

Very variableVery variable Infection caused by inhalation in almost Infection caused by inhalation in almost

all casesall cases Most cases include symptomatic Most cases include symptomatic

pulmonary infectionpulmonary infection

WisconsinWisconsin

2 retrospective studies2 retrospective studies– Centers for Disease Control and Centers for Disease Control and

Prevention (CDC). Blastomycosis--Prevention (CDC). Blastomycosis--Wisconsin, 1986-1995. (1996)Wisconsin, 1986-1995. (1996)

– Baumgardner DJ. Halsmer SE. Egan G. Baumgardner DJ. Halsmer SE. Egan G. Symptoms of pulmonary blastomycosis: Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. (2004)northern Wisconsin, United States. (2004)

CDCCDC

All reported cases in WI 1986-1995All reported cases in WI 1986-1995– 670 cases670 cases– 29 fatal29 fatal

Primary pulmonary disease without Primary pulmonary disease without extrapulmonary manifestationsextrapulmonary manifestations– 76%76%

Extrapulmonary disease onlyExtrapulmonary disease only– 18%18%

Pulmonary and ExtrapulmonaryPulmonary and Extrapulmonary– 6%6%

BaumgardnerBaumgardner

Retrospective investigation of 170 Retrospective investigation of 170 reported cases in Vilas Countyreported cases in Vilas County– 1979-20011979-2001– 91% pulmonary symptoms91% pulmonary symptoms

Pulmonary cases contacted and Pulmonary cases contacted and interviewed (118 of 154)interviewed (118 of 154)

Patients with Pulmonary BlastoPatients with Pulmonary Blasto

Baumgardner, etal.Baumgardner, etal.

CoughCough 90%90%

FeverFever 75%75%

Night SweatsNight Sweats 68%68%

Weight LossWeight Loss 68%68%

Chest PainChest Pain 63%63%

DyspneaDyspnea 54%54%

MyalgiasMyalgias 50%50%

HemoptysisHemoptysis 18%18%

Common Extrapulmonary SxCommon Extrapulmonary Sx SkinSkin

– Verrucous or ulcerativeVerrucous or ulcerative BoneBone

– Any boneAny bone– Xrays not specificXrays not specific

GUGU– Prostatitis and epididymoorchitisProstatitis and epididymoorchitis

CNSCNS– Epidural or cranial abscessesEpidural or cranial abscesses

DiagnosisDiagnosis

DiagnosisDiagnosis– HistologyHistology– CultureCulture

»Easy to cultureEasy to culture SerologySerology

– Not sensitive or specificNot sensitive or specific– 95% cross reactivity with Histo95% cross reactivity with Histo– Also cross-reactive with Also cross-reactive with

paracoccidiodomycosisparacoccidiodomycosis

TreatmentTreatment

No good RCTsNo good RCTs Guidelines based on small open label Guidelines based on small open label

studies, case series and expert opinionstudies, case series and expert opinion Ampho for life threateningAmpho for life threatening Itraconazole for mild to moderateItraconazole for mild to moderate At least 6 monthsAt least 6 months

IDSA GuidelinesIDSA Guidelines

PulmonaryPulmonary– Life threatening – Amphotericin BLife threatening – Amphotericin B– Mild/Mod – ItraconazoleMild/Mod – Itraconazole

DisseminatedDisseminated CNS – Ampho BCNS – Ampho B Non-CNSNon-CNS

– Life threatening – Ampho BLife threatening – Ampho B– Mild/Mod - ItraconazoleMild/Mod - Itraconazole

Clinical Follow-upClinical Follow-up

ConclusionsConclusions

Treatment of osteomyelitisTreatment of osteomyelitis– Bone CultureBone Culture– Reassess when not respondingReassess when not responding

Manifestations of BlastoManifestations of Blasto– Pulmonary most commonPulmonary most common– Can affect almost any organCan affect almost any organ

TreatmentTreatment– Ampho or ItraconazoleAmpho or Itraconazole– No good trials of efficacyNo good trials of efficacy

ReferencesReferences

Centers for Disease Control and Prevention (CDC). Centers for Disease Control and Prevention (CDC). Blastomycosis--Wisconsin, 1986-1995. MMWR - Morbidity & Blastomycosis--Wisconsin, 1986-1995. MMWR - Morbidity & Mortality Weekly Report. 45(28):601-3, 1996 Jul 19. Mortality Weekly Report. 45(28):601-3, 1996 Jul 19.

Baumgardner DJ. Halsmer SE. Egan G. Symptoms of Baumgardner DJ. Halsmer SE. Egan G. Symptoms of pulmonary blastomycosis: northern Wisconsin, United States. pulmonary blastomycosis: northern Wisconsin, United States. Wilderness & Environmental Medicine. 15(4):250-6, 2004. Wilderness & Environmental Medicine. 15(4):250-6, 2004.

Chapman SW. Bradsher RW Jr. Campbell GD Jr. Pappas PG. Chapman SW. Bradsher RW Jr. Campbell GD Jr. Pappas PG. Kauffman CA. Practice guidelines for the management of Kauffman CA. Practice guidelines for the management of patients with blastomycosis. Infectious Diseases Society of patients with blastomycosis. Infectious Diseases Society of America. Clinical Infectious Diseases. 30(4):679-83, 2000 Apr. America. Clinical Infectious Diseases. 30(4):679-83, 2000 Apr.