Cerebellar Blastomycotic Abscesses

A comatose 29-year-old woman was brought to the emergency department. Her family reported that she had been well until 4 days earlier, when headache and fever developed. She went to another hospital at that time and was told she had an abscessed tooth. She was given erythromycin, and the tooth was extracted the following day. The patient's headache and fever worsened; a sore throat also developed, and a rash appeared on her trunk, arms, and legs. The family denied any HIV risk factors, unusual medical history, recent travel, and exposure to persons with infectious diseases.

The patient's temperature was 39°C (102.2°F) when she was admitted to the hospital. At this point, she was unresponsive, her pupils were nonreactive, and intubation was required. She had a diffuse, vesicular, erythematous rash with occasional pustules on her face, trunk, and limbs; thrush; and vesicles on the soft palate. Results of complete blood cell count, blood chemistry tests, blood gas analysis, chest film, HIV test, and cerebrospinal fluid studies were normal. Her CD4 lymphocyte count was 753/mL. An MRI of the head showed multiple cerebellar nodules, hydrocephalus, and herniation (A).

The patient's condition deteriorated, report Drs Joan R. Allman and Fred T. Kerns of Charleston, W Va, and on the fourth hospital day, an electroencephalogram and neurologic examination confirmed brain death. Autopsy revealed disseminated blastomycosis with extensive abscesses of the cerebellum and similar involvement of the kidneys, lungs, and liver.

Examination of a hematoxylin-eosin stain of autopsied brain tissue (× 100) is remarkable for abscess (B).

A Grocott-Gomori methenamine–silver nitrate stain of the cerebellar abscess (× 250) shows silver-stained walls of fungal yeast forms that demonstrate characteristic broad-based budding (C). Cultures of specimens from all the organs mentioned above were positive for Blastomyces dermatitidis.