Cutaneous blastomycosis masquerading as bacterial folliculitis: a diagnostic challenge

A patient presented with persistent pustular, violaceous nodules and a tense bulla that was initially diagnosed as bacterial folliculitis. Despite four courses of oral antibiotics, there was no clinical improvement. The patient's cutaneous symptoms progressed, and he developed systemic symptoms. A punch biopsy, blood studies and a chest CT confirmed a diagnosis of disseminated blastomycosis. The patient improved with itraconazole. This case highlights the diagnostic challenges of atypical cutaneous blastomycosis, which can mimic bacterial folliculitis and lead to delays in treatment. Clinicians should consider deep fungal infections in patients with unusual or unresolved skin lesions, especially in endemic areas and regardless of immune status. Optimal treatment with itraconazole requires attention to drug absorption and monitoring of serum levels. Early biopsy and fungal-specific studies are essential for accurate diagnosis and to guide appropriate therapy of blastomycosis.