Cutaneous blastomycosis without evidence of pulmonary involvement

Blastomycosis is an infection that is often associated with recent military, occupational, or recreational activities near damp soil in various endemic regions, including the Great Lakes and major river valleys in the Midwest as well as various overseas regions. In the great majority of cases, the disease presents as a primary pulmonary disease with or without extrapulmonary involvement. We present a case of cutaneous blastomycosis with no evidence of pulmonary or other systemic involvement. With such presentations, the disease is presumed to have spread hematogenously with the asymptomatic or minimal primary pulmonary infection having resolved spontaneously. The patient's diagnosis was made with positive cultures and histologic examinations revealing features that are quite characteristic of blastomycosis. The patient responded to treatment with itraconazole for 6 months with no recurrence after 1 year. A high index of suspicion must be maintained when evaluating patients with progressive ulcerating or verrucous lesions that do not respond to traditional antibiotic therapy, especially with a history of recent activities in the endemic regions.