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Fig. 6.52 A-D. Pulmonary blastomycosis. A, B A large mass in the left upper lobe (arrows). C The same mass on a CT scan (arrows). This was removed surgically and was found to be a granulomatous mass within which was evidence of blastomycosis: the patient was a 39-year-old man with a 9-month history of cough. D A progressive infection in the right upper lobe, with cavitation and pleural reaction: there is hilarlymphadenopathy. (A-C courtesy of Dr. L. R. Brown et al and Mayo Clin Proc 1991; D courtesy of Professor Harold Jacobson)


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Clinical Characteristics

The clinical presentation varies between children and adults.

Juvenile infections are often subacute but progressive and equally common in girls and boys. Many children have abdominal symptoms: pain, diarrhea, palpable masses, and even symptoms of an acute abdomen. There may be hepatosplenomegaly, fever, and weight loss. Lymphadenopathy may be generalized, and the majority of children will have enlarged lymph nodes in the neck or submandibular area, often with draining sinuses. Chest radiographs will show mediastinal and hilar lymphadenopathy; sputum culture may be positive even when there is no clinical evidence of chest infection. Because of fungemia, there may be acute and relapsing episodes and multiple skin lesions (Fig. 6.54 A, B). The acute form in younger patients can be rapidly fatal.

Paracoccidioidomycosis in adults tends to run an indolent course, sometimes causing illness many years after departure from the endemic area. Oral mucous membrane infection is common, affecting the gums, tongue, lips, or palate (Fig. 6.54 D-F). The mucosal granulomas on the soft paplate have a "mulberry" pattern, the tongue becomes nodular and there may be painful ulcers in the mouth, making eating difficult. Pharyngeal infection may cause hoarseness and the nasal cartilage may be infected. Coexisting skin lesions occur but less commonly than those in the mouth. When the skin is infected, it is usually on the face, but in severe infections lesions may appear anywhere on the body: the majority will be papular with small central ulcers, but these may enlarge into an elevated plaque, ulcer (Fig. 6.54 C) or dry warty area.

Lymphadenitis does not seem to be related to the site of mucocutaneous lesions. Clinical examination may show enlarged cervical and submandibular lymph nodes, but imaging often reveals similar lymphadenopathy in the mediastinum, axilla, and femoral regions.

Pulmonary infection is quite common at autopsy but seldom presents clinically: if apparent, the complaints then are of cough, sputum, and hemoptysis, clinically suggesting tuberculosis.

In the disseminated disease, almost any organ can be involved, including the adrenal glands, small and large bowel, liver, and meninges. Infection occurs in bones and joints, either separately or under skin lesions. The first clinical evidence of infection may be at any of these sites and a lung focus may be found subsequently. Involvement of the CNS by granulomas, arteritis, or thrombosis will result in clinical symptoms related to the site.



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