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Disseminated blastomycosis presenting as mastoiditis and epidural abscess.


Blastomycosis is a systemic pyogranulomatous fungal infection that primarily involves the lungs and is caused by the conidia of Blastomyces dermatitdis. (1) Lymphohematogenous dissemination frequently occurs and extrapulmonary disease involving the skin, bones, and genitourinary system is common. (1) Temporal bone and middle ear involvement is extremely rare and presents a diagnostic challenge. We present a case of disseminated blastomycosis presenting as mastoiditis with epidural abscess. An approval to describe this case has been obtained from the institutional review board of West Virginia University.

Case report

A 75 year-old female was referred with a 1 month-history of worsening right post-auricular swelling associated with aural fullness, temporal headache, and pulsatile tinnitus. She denied ear infections, dizziness, or systemic symptoms. Her medical history was noteworthy for chronic lymphocytic leukemia (CLL) and well-controlled diabetes mellitus. An outside general surgeon had attempted excision of the mass but encountered a pulsatile lesion and was concerned about a possible cerebrospinal fluid leak. Physical examination showed a tender and bulging scalp incision located 2cm posterior to the superior portion of the right pinna. Right ear exam showed a dull tympanic membrane. The rest of her examination was unremarkable.

CT scans of the brain and temporal bones showed right mastoid and middle ear effusions with erosion of the tegmen mastoideum posteriorly, and an epidural abscess with transcalvarial extension into the posterior auricular subcutaneous region (Figure 1). Of interest, the scan also showed dehiscence of the superior semicircular canal with moth-eaten appearance of the adjacent tegmen. Brain MRI showed no intraparenchymal or sigmoid/ transverse sinus involvement.

Incision and debridement of the wound, and tympanostomy with PE tube insertion were performed. A 1.5cm defect in the skull was noted just posterior and superior to the mastoid area. Cerebrospinal fluid was not encountered. Cultures were taken from the epidural drainage and ear fluid. Histopathological evaluation of epidural tissue showed predominantly chronic and granulomatous inflammation with numerous large broad based budding organisms seen in black on GMS stain (Figure 2). Both epidural and ear fluid grew Blastomyces dermatitidis.

Blood cultures and serum Blastomyces antibody test were negative. CT chest without IV contrast confirmed a systemic infection in the lungs and mediastinal and axillary lymph nodes. On the recommendations of the infectious diseases team, the patient completed 5 days of intravenous Amphotericin B (total of 1 gm) and then was switched to oral voriconazole 200 mg twice per day, and was discharged home 7 days after her surgery on oral voriconazole therapy. Her audiogram, performed post-operatively, showed mild to severe mixed hearing loss on the right and normal to severe sensorineural hearing loss on the left, with large volume type B tympanogram on the right side. She completed a total of 6 months of oral voriconazole. Twelve months follow up showed no recurrence of the infection.


Both acute and chronic infections with blastomycosis may mimic other diseases due to the rarity and variability of the presentation. (1) Bone involvement, for instance, may be thought to be malignant metastatic lesions. Therefore a high index of suspicion is needed, and aggressive collection of samples for pathologic and microbiologic examination is essential for accurate diagnosis. Also, the infection tends to present more commonly as disseminated and aggressive infection in immunocompromised patients with a higher mortality rate. (2) Abnormalities of T-lymphocyte function, such as hematologic abnormalities (including CLL) predispose to a more aggressive and serious infection. (2)

While the lungs are the usual portal of entry and the most common site of infection in Blastomycosis, extrapulmonary involvement has been reported to involve almost every organ. Head and neck involvement with blastomycosis has been reported most commonly in the larynx and involving oral and nasal mucosa. (3) Temporal bone involvement is extremely rare, and the first case was reported by Louis III in 1972. (4) Since then, several reports of temporal bone involvement have appeared. Istorico et al (5) in 1991 reported 2 cases of blastomycotic otitis media, with facial nerve paresis in one of the two patients. Three additional cases of otitis media with petrous apex and cranial base involvement were subsequently reported by Farr et al (6) in 1992, Weingarten et al (7) in 1993, and Blackledge et al (8) in 2001. Our case is unique in its presentation. It represents a case of disseminated blastomycosis with mastoiditis, and epidural and posterior auricular subcutaneous abscess as the presenting sign. It is also noteworthy for the superior semicircular canal dehiscence which most likely is an incidental finding.

Prompt initiation of systemic treatment in disseminated blastomycosis is essential for optimal prognosis. All patients with disseminated disease require initial treatment with intravenous Amphotericin B. (9) A cumulative dose of 1g or greater is recommended. Blastomyces dermatitidis is generally susceptible to voriconazole which has been successfully used in treating CNS infections due to its ability to achieve therapeutic concentration in the brain and CSF. (10) A 6-month treatment course is recommended.


We thank the Department of Pathology of West Virginia University for providing the pathology photomicrograph.


(1.) Saccente M, Woods GL. Clinical and laboratory update on blastomycosis. Clin Microbiol Rev 2010;23:367.

(2.) Pappas PG. Blastomycosis in the immunocompromised patient. Semin Respir Infect. 1997 Sep;12(3):243-51.

(3.) Reder PA, Neel HB. Blastomycosis in otolaryngology: review of a large series. J Infect Dis 1987;155:262-4.

(4.) Louis III T, Lockey MW. Blastomycosis of the middle ear cleft. South Med J. 1974;67(12):1489-91.

(5.) Istorico LJ, Sanders M, Jacobs RF, Gilleon S, Glasier C, Bradsher RW. Otitis media due to blastomycosis: report of two cases. Clin Infect Dis. 1992;14(1):355-8.

(6.) Farr RC, Gardner G, Acker JD, Brint JM, Haglund LF, Land M, Schweitzer JB, West BC. Blastomycotic cranial osteomyelitis. Am J Otol. 1992;13(6):582-6.

(7.) Weingarten RT, Hohn F, Goldman M, Gruber B, Ferguson LR. Blastomycosis of the skull base. Skull Base Surg. 1993;3(2):69-73.

(8.) Blackledge FA, Newlands SD. Blastomycosis of the petrous apex. Otolaryngol Head Neck Surg. 2001;124(3):347-9.

(9.) Chapman SW, Dismukes WE, Proia LA, et al. Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2008;46:1801.

(10.) Bakleh M, Aksamit AJ, Tleyjeh IM, Marshall WF. Successful treatment of cerebral blastomycosis with voriconazole. Clin Infect Dis 2005;40:e69

Chadi A. Makary, MD

Department of Otolaryngology, West Virginia University

School of Medicine, Morgantown, WV

Thomas D. Roberts, MD

Department of Radiology, West Virginia University

School of Medicine, Morgantown, WV

Stephen J. Wetmore, MD, MBA

Department of Otolaryngology, West Virginia University

School of Medicine, Morgantown, WV

Corresponding Author: Chadi A. Makary, MD, Department of Otolaryngology, Health Sciences Center South, Morgantown, WV 26506; email
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Title Annotation:Case Report
Author:Makary, Chadi A.; Roberts, Thomas D.; Wetmore, Stephen J.
Publication:West Virginia Medical Journal
Article Type:Clinical report
Geographic Code:1U5WV
Date:Jan 1, 2014
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