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MULTIFOCAL OSTEOMYELITIS SECONDARY TO BLASTOMYCOSIS
Authored By: Keith Fischer and Jonathan Weiss.
Patient: 13 year old male
History:

Patient presents with a chronic left upper lobe opacity, low grade fevers, cough and arthralgias.

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Fig. 1
CXR 3 months prior

Fig. 2
Current CXR

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7
Image Size:[small][as-submitted]

Findings:

RADIOPHARMACEUTICAL: 13.0 mCi Tc-99m MDP i.v.

There are multiple foci of radiotracer uptake predominately involving the appendicular skeleton (Figures 3 and 4).  Specifically, there are foci of intense radiotracer uptake within the right first proximal phalanx extending into the first metatarsal head, distal left second metatarsal, right calcaneus, distal right tibia, distal left tibia, right elbow involving the distal humerus and olecranon, posterolateral left seventh rib, manubrium, right coracoid process, base of the right fourth proximal phalanx and in the left third metacarpal head.

The CXR preformed three months prior shows an opacity within the left upper lobe (Figure 1) that is persistent three months later (Figure 2).

Corresponding X-rays show predominately lytic lesions in the areas of abnormal radiotracer uptake (Figures 5-7).

DDx:

Multifocal osteomyelitis (most likely given history)

Metastatic disease (unlikely given the appendicular distribution of disease)

Diagnosis:

Multifocal osteomyelitis secondary to blastomycosis

General Discussion:

Blastomycosis infection is a highly variable disease that ranges from an asymptomatic lung infection to a disseminated fatal disease.  The disease is caused by Blastomyces dermatitidis which is a dimorphic fungus.  Primary infection occurs in the lungs and is caused by inhalation of spores that convert to an invasive yeast within the body.  Most U.S. infections occur in the Great Lakes region and along the Ohio and Mississippi rivers.

Over half of blastomycosis infections are asymptomatic.  Pulmonary blastomycosis may become disseminated and involve the skin, bones, prostate, epididymis, or central nervous system. Other organs are less commonly involved.  Primary disease in the skin can also occur through direct trauma.  Patients are treated with antifungal medications with a mortality of less than 10%; however, mortality is worse in immunocompromised patients. 

References: Steele, R and Shetty, A (2008, 07 28). Blastomycosis. Retrieved June 10, 2009, from eMedicine Web site: http://emedicine.medscape.com/article/961731-overview
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Additional Details:

Case Number: 173393Owner(s): Keith Fischer and Jonathan WeissLast Updated: 02-07-2013
Anatomy: Skeletal System   Pathology: Infection
Modality: Conventional Radiograph, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: bsnm, osteomyelitisACR: 00004.21000

Case has been viewed 24 times.
Certified by Keith Fischer on 06-26-2009

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