Multifocal Osseous and Soft Tissue Blastomycosis Infection

A 15-year-old male with no significant medical history presented with a 4-month history of bilateral wrist pain and a 2-month history of rapidly growing, spontaneously ulcerating bilateral volar wrist nodules. He denied fevers, fatigue, weight loss, illicit drug use/injection, or local trauma including self-harming behavior. Ultrasound and MRI demonstrated strikingly symmetric ill-defined mass-like tissue underlying each wound invading the bilateral distal radii but without mass effect or invasion of traversing bilateral radial arteries and flexor carpi radialis tendons. Imaging of the pelvis and spine revealed multifocal thoracolumbar spine and right proximal femoral involvement. Excisional biopsy of the wrist lesions demonstrated an active inflammatory process with broad-based budding yeast confirmed to be Blastomyces spp. on fungal cultures. The case herein describes an uncommon example of disseminated blastomycosis osseous and soft tissue infection without pulmonary involvement. · Disseminated blastomycosis can present with multifocal osteomyelitis and soft tissue infections with spontaneous skin rupture.. · Blastomyces infection can be locally aggressive despite an indolent clinical course.. · In the setting of strikingly symmetric processes, indolent fungal or other atypical infections should be considered.. · Pulmonary involvement is classically associated with but not always present in the setting of disseminated blastomycosis..