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Case Reports

Abstract

A 27-year-old male presented with a persistent non-healing lesion on his left medial thigh, first noticed three years prior and managed as an abscess. Prior biopsy of the area only noted a fistula tract with associated acute and chronic inflammation. After failed empiric antifungal treatment, the patient underwent excision of the lesion, which demonstrated pseudoepitheliomatous hyperplasia and granulation tissue with numerous neutrophils in the epidermis and dermis. Grocott methenamine silver (GMS) special stain revealed fungal organisms with broad-based budding, consistent with cutaneous blastomycosis.

A 45-year-old male demonstrated multiple painful subcutaneous nodules in the chest and bilateral upper and lower extremities. Two weeks prior, the patient had a core biopsy of a spiculated mass in the right upper lobe which revealed rare broad-based budding yeasts on GMS stain. An excision of one of the subcutaneous nodules on the chest showed deep dermal/subcutaneous non-caseating granulomatous inflammation with numerous neutrophils and eosinophils, however GMS failed to highlight any organisms. Thorough high-power examination of the lesion on H&E stain revealed refractile fungal elements, a broad-based budding yeast was seen in the acid-fast bacillus (AFB) special stain, consistent with disseminated blastomycosis.

Herein, we describe two cases of blastomycosis with divergent clinical presentations. These cases highlight the importance of having a high index of suspicion for microorganisms when abundant neutrophils are seen within the dermis. Performing both a thorough microscopic evaluation and special stains for microorganisms are essential, and the absence of organisms on special stains may not adequately rule out an infectious process.