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Eyelid blastomycosis in British Columbia
CORRESPONDENCE Eyelid blastomycosis in British Columbia An 88-year-old female from Vancouver Island developed diffuse right upper and lower eyelid erythema which evolved into two red, scaly, nontender nodules over 2 weeks. There was no history of trauma nor systemic complaints. There was minimal response to warm compresses and tobramycin-dexamethasone ointment. Attempted drainage of one nodule yielded scant material, but the patient noticed the rapid development of a new nodule at one of the anesthetic needle puncture sites. On referral to our clinic, she had induration of the right upper and lower lid with hyperemic and ezcematoid skin. There were two discrete nontender subcutaneous nodules at the temporal right upper lid and a separate one where the anesthetic needle had penetrated centrally (Fig. 1). One nodule was biopsied and purulent material submitted for culture. Histopathologic examination of the biopsy specimen showed epidermal hyperplasia overlying a dermal area of abscess formation surrounded by granulomatous in-
Fig. 2—(A) Low power photomicrograph of the biopsy showing pseudoepitheliomatous hyperplasia and dermal inflammation (H&E, ⴛ20). (B) Higher power showing pyo-granulomatous inflammation with one giant cell containing a budding organism marked with an asterisk (H&E, ⴛ100). (C) Silver stain showing several thick-walled organisms, some with broad-based budding characteristic of blastomyces dermatiditis (Grocott, ⴛ400). Fig. 1—(A) Two discrete nodules on the right upper lid and one on the temporal lower lid. (B) Same eye showing a preseptal, raised scaly patch and two needle marks centrally where patient reported a new nodule rapidly evolved.
flammation (Figs. 2A and 2B). Grocott and periodic acid-schiff (PAS) stains revealed the presence of thickwalled fungal organisms, some showing wide-based CAN J OPHTHALMOL—VOL. 47, NO. 3, JUNE 2012
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Correspondence budding characteristic of blastomyces dermatiditis, confirmed by the National Centre for Mycology in Edmonton, Alberta (Fig. 2C). Cultures were negative for bacteria. The patient was started on oral and topical itraconazole and her eyelid lesions have gradually resolved. A systemic workup for pulmonary involvement was negative. Blastomycosis is caused by the dimorphic fungus Blastomyces dermatitidis and was first described by Thomas Gilchrist in 1894.1,2 It has been documented in Canada since 1910, with endemic areas in forests and near waterways in Northwestern Ontario and in Manitoba. There has only been one reported case in British Columbia.3 Our patient lived in Manitoba 8 years previously but had not returned since. Presumably her disease resulted from reactivation of a pulmonary infection that resolved spontaneously, as she has no history of having been treated previously for the disease.1 The organism thrives in warm, acidic, moist soil, and infection results from inhaling spores released from this reservoir. Following an incubation period of 1-3 months, a flu-like illness develops that may be self-limited or progress to chronic illness. The disease occurs in otherwise healthy individuals. No person-to-person transmission occurs except in unusual circumstances.1 Skin lesions are the most common extrapulmonary manifestation and may be the first sign of infection. Rarely, primary cutaneous blastomycosis may occur through puncture with contaminated material. Self-inoculation through an anesthetic needle has not been reported previously. Blastomycosis of the eyelid is rare and may be mistaken for a chalazion, basal cell, or squamous cell carcinoma. Our case was referred as a possible malignancy.4,5
Prophylactic lateral canthotomy and cantholysis allow graded reconstruction of eyelids with multifocal stellate lacerations Lateral canthotomy and cantholysis are well described in the following settings: (i) acute management of retrobulbar hemorrhage1; and (ii) reconstruction of fullthickness eyelid defects.2 I describe a patient who was involved in a motor vehicle accident and presented with multifocal stellate lacerations of upper and lower eyelids as well as a scleral rupture on the ipsilateral side. A controlled lateral canthotomy with disinsertion of the inferior and superior crus of the lateral canthal tendon allowed complete reconstruction of the eyelids in the same setting as the globe repair. A staged repair of the induced lateral canthal deformity resulted in functional eyelids as well as a good visual outcome.
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CAN J OPHTHALMOL—VOL. 47, NO. 3, JUNE 2012
Preferred therapy is itraconzole 200-400 mg/day for 6 months. Amphotericin-B is used for pregnant women or those with central nervous system involvement. The mortality rate is 60% in untreated systemic disease, but is reduced to 10% with appropriate therapy. Our patient remains well. This report indicates that blastomycosis should be considered in the differential diagnosis of skin lesions even outside of endemic areas. Ryan C. Rodriguez,* Elizabeth Cornock,‡ Valerie A. White,† Peter J. Dolman* From the Departments of *Ophthalmology and Visual Sciences, and †Pathology and Laboratory Sciences, University of British Columbia, Vancouver, B.C.; and the ‡Comox-Strathcona Regional Health District, Comox, B.C. Correspondence to: Peter J. Dolman, MD, FRCSC: [email protected] REFERENCES 1. Saccente M, Woods GL. Clinical and laboratory update on blastomycosis. Clin Microbiol Rev. 2010;23:367-81. 2. DiSalvo AF. The ecology of blastomyces dermatitidis. In: Al-Doory Y, DiSalvo AF, Eds. Blastomycosis. Plenum Medical. New York, N.Y. 1992: 43-73. 3. Communicable Disease Control Unit. Communicable Disease Management Protocol—Blastomycosis. Sept. 2007. Available at: http://www. gov.mb.ca/health/publichealth/cdc/protocol/blastomycosis.pdf. 4. Bartley GB. Blastomycosis of the eyelid. Ophthalmology. 1995 Dec;102: 2020-3. 5. Pemberton JD, Vidor I, Sivak-Callcott JA, Bailey NG, Sarwari AR. North American Blastomycosis of the eyelid. Ophthal Plast Reconstr Surg. 2009; 25:230-2. Can J Ophthalmol 2012;47:e1– e2
0008-4182/11/$-see front matter © 2012 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. doi:http://dx.doi.org/10.1016/j.jcjo.2012.03.008
CASE REPORT A 17-year-old female was involved in an accident in which her car hit a tree. She suffered a closed head injury and was intubated at the scene. The shattered windshield was associated with multifocal right upper and lower eyelid stellate lacerations involving the tarsal plate, lid margin, and lateral canthus (Fig. 1). She was transported to the Ohio State University emergency room and admitted to the intensive care unit. A CT scan did not reveal any intraocular or intraorbital foreign bodies. There was mild orbital congestion but no relative afferent papillary defect. Under anesthesia, the anterior chamber and vitreous cavities were clear and the retina was attached. The intraocular pressures were 12 mm Hg bilaterally by Tonopen. In the superotemporal quadrant, a brown tissue was noted beneath the conjunctiva, raising suspicion for a small area of scleral rupture. This was explored under the operating microscope and repaired by 3 interrupted 8-0 Vicryl sutures.
Fig. 2—(A) Low power photomicrograph of the biopsy showing pseudoepitheliomatous hyperplasia and dermal inflammation (H&E, ⴛ20). (B) Higher power showing pyo-granulomatous inflammation with one giant cell containing a budding organism marked with an asterisk (H&E, ⴛ100). (C) Silver stain showing several thick-walled organisms, some with broad-based budding characteristic of blastomyces dermatiditis (Grocott, ⴛ400). Fig. 1—(A) Two discrete nodules on the right upper lid and one on the temporal lower lid. (B) Same eye showing a preseptal, raised scaly patch and two needle marks centrally where patient reported a new nodule rapidly evolved.
flammation (Figs. 2A and 2B). Grocott and periodic acid-schiff (PAS) stains revealed the presence of thickwalled fungal organisms, some showing wide-based CAN J OPHTHALMOL—VOL. 47, NO. 3, JUNE 2012
e1
Correspondence budding characteristic of blastomyces dermatiditis, confirmed by the National Centre for Mycology in Edmonton, Alberta (Fig. 2C). Cultures were negative for bacteria. The patient was started on oral and topical itraconazole and her eyelid lesions have gradually resolved. A systemic workup for pulmonary involvement was negative. Blastomycosis is caused by the dimorphic fungus Blastomyces dermatitidis and was first described by Thomas Gilchrist in 1894.1,2 It has been documented in Canada since 1910, with endemic areas in forests and near waterways in Northwestern Ontario and in Manitoba. There has only been one reported case in British Columbia.3 Our patient lived in Manitoba 8 years previously but had not returned since. Presumably her disease resulted from reactivation of a pulmonary infection that resolved spontaneously, as she has no history of having been treated previously for the disease.1 The organism thrives in warm, acidic, moist soil, and infection results from inhaling spores released from this reservoir. Following an incubation period of 1-3 months, a flu-like illness develops that may be self-limited or progress to chronic illness. The disease occurs in otherwise healthy individuals. No person-to-person transmission occurs except in unusual circumstances.1 Skin lesions are the most common extrapulmonary manifestation and may be the first sign of infection. Rarely, primary cutaneous blastomycosis may occur through puncture with contaminated material. Self-inoculation through an anesthetic needle has not been reported previously. Blastomycosis of the eyelid is rare and may be mistaken for a chalazion, basal cell, or squamous cell carcinoma. Our case was referred as a possible malignancy.4,5
Prophylactic lateral canthotomy and cantholysis allow graded reconstruction of eyelids with multifocal stellate lacerations Lateral canthotomy and cantholysis are well described in the following settings: (i) acute management of retrobulbar hemorrhage1; and (ii) reconstruction of fullthickness eyelid defects.2 I describe a patient who was involved in a motor vehicle accident and presented with multifocal stellate lacerations of upper and lower eyelids as well as a scleral rupture on the ipsilateral side. A controlled lateral canthotomy with disinsertion of the inferior and superior crus of the lateral canthal tendon allowed complete reconstruction of the eyelids in the same setting as the globe repair. A staged repair of the induced lateral canthal deformity resulted in functional eyelids as well as a good visual outcome.
e2
CAN J OPHTHALMOL—VOL. 47, NO. 3, JUNE 2012
Preferred therapy is itraconzole 200-400 mg/day for 6 months. Amphotericin-B is used for pregnant women or those with central nervous system involvement. The mortality rate is 60% in untreated systemic disease, but is reduced to 10% with appropriate therapy. Our patient remains well. This report indicates that blastomycosis should be considered in the differential diagnosis of skin lesions even outside of endemic areas. Ryan C. Rodriguez,* Elizabeth Cornock,‡ Valerie A. White,† Peter J. Dolman* From the Departments of *Ophthalmology and Visual Sciences, and †Pathology and Laboratory Sciences, University of British Columbia, Vancouver, B.C.; and the ‡Comox-Strathcona Regional Health District, Comox, B.C. Correspondence to: Peter J. Dolman, MD, FRCSC: [email protected] REFERENCES 1. Saccente M, Woods GL. Clinical and laboratory update on blastomycosis. Clin Microbiol Rev. 2010;23:367-81. 2. DiSalvo AF. The ecology of blastomyces dermatitidis. In: Al-Doory Y, DiSalvo AF, Eds. Blastomycosis. Plenum Medical. New York, N.Y. 1992: 43-73. 3. Communicable Disease Control Unit. Communicable Disease Management Protocol—Blastomycosis. Sept. 2007. Available at: http://www. gov.mb.ca/health/publichealth/cdc/protocol/blastomycosis.pdf. 4. Bartley GB. Blastomycosis of the eyelid. Ophthalmology. 1995 Dec;102: 2020-3. 5. Pemberton JD, Vidor I, Sivak-Callcott JA, Bailey NG, Sarwari AR. North American Blastomycosis of the eyelid. Ophthal Plast Reconstr Surg. 2009; 25:230-2. Can J Ophthalmol 2012;47:e1– e2
0008-4182/11/$-see front matter © 2012 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. doi:http://dx.doi.org/10.1016/j.jcjo.2012.03.008
CASE REPORT A 17-year-old female was involved in an accident in which her car hit a tree. She suffered a closed head injury and was intubated at the scene. The shattered windshield was associated with multifocal right upper and lower eyelid stellate lacerations involving the tarsal plate, lid margin, and lateral canthus (Fig. 1). She was transported to the Ohio State University emergency room and admitted to the intensive care unit. A CT scan did not reveal any intraocular or intraorbital foreign bodies. There was mild orbital congestion but no relative afferent papillary defect. Under anesthesia, the anterior chamber and vitreous cavities were clear and the retina was attached. The intraocular pressures were 12 mm Hg bilaterally by Tonopen. In the superotemporal quadrant, a brown tissue was noted beneath the conjunctiva, raising suspicion for a small area of scleral rupture. This was explored under the operating microscope and repaired by 3 interrupted 8-0 Vicryl sutures.