Pulmonary blastomycosis - An appraisal of diagnostic techniques

Objectives: Pulmonary blastomycosis often mimics bacterial pneumonia or bronchogenic carcinoma, which may result in delayed therapy or the performance of unnecessary diagnostic procedures. We have reviewed the utilization of diagnostic techniques in the workup of patients with pulmonary blastomycosis, defined their diagnostic yields, and proposed an optimal diagnostic approach for the patient in whom pulmonary blastomycosis is considered. Design: Retrospective chart review of all patients with the diagnosis of blastomycosis at a major academic medical center. Results: Of the 119 patients with blastomycosis, 56 (47%) had pulmonary involvement. A total of 92 specimens were obtained by noninvasive means (sputa, 72 specimens; tracheal secretions, 5 specimens; and gastric washings, 15 specimens) in 35 patients. KOH smears were prepared from 22 of those specimens (24%). The diagnostic yield from these culture specimens obtained by noninvasive means was 86% per patient, and 75% per single sample. The diagnostic yields from KOH smears were 46% and 36%, respectively. Flexible bronchoscopy was performed in 24 patients and yielded a diagnosis in 22 (92%). Cultures of bronchial secretions (19 patients) and BAL fluid (6 patients) were positive in 100% and 67% of patients, respectively. The corresponding yields of KOH preparations were 17% (1 of 6 preparations) and 50% (3 of 6 preparations), respectively. Pathology specimens including those from bronchoscopic lung biopsies (nine patients), bronchial brushings (two patients), and bronchoscopic needle aspiration (one patient) were positive in 22%, 50%, and 0% of cases, respectively. Cytology was usually performed to exclude malignancy and was positive for Blastomyces dermatitidis in five patients (sputum, three patients; bronchial washings, two patients). Thoracotomy was performed in 11 cases, and in all patients the procedure yielded a diagnosis. Serology results were available in 25 patients. Immunodiffusion was positive in 10 patients (40%), and complement fixation in 4 patients (16%). Conclusions: In patients with pulmonary blastomycosis, the positive yield from respiratory specimen cultures is high, but the confirmation of a diagnosis may take up to 5 weeks. Wet smears and cytology examinations of respiratory specimens provide quicker diagnoses but are underutilized. Their routine use is recommended in endemic areas. Commonly used serologic assays are insensitive and are not useful for diagnostic screening.