A rare opportunistic infection in a woman with systemic lupus erythematosus and multiple skin lesions

Abstract

Cutaneous lesions in patients with systemic lupus erythematosus (SLE) represent diagnostic challenges. Opportunistic infections should be considered when lupus patients are on immunosuppressive therapy and other causes, such as disease activity, are less likely to explain the skin lesions. Within the spectrum of skin opportunistic infections that might occur in SLE patients, Blastomyces dermatitidis should be suspected when acid-fast positive material with no bacilliform organisms is seen on Ziehl-Nielsen skin biopsy preparations. In this study, we describe one patient with SLE on immunosuppressive therapy, who developed cutaneous blastomycosis despite living in a non-endemic area. Because of lack of awareness about this association and misinterpretation of the skin biopsy results, the diagnosis of atypical mycobacterial infection was initially considered. Subsequent proper tissue staining and interpretation revealed the correct diagnosis of disseminated cutaneous blastomycosis. This description represents the first report of this rare opportunistic skin infection in SLE, illustrating the importance of performing correct preparation and elucidation of the skin biopsy to avoid misdiagnosis and treatment delay.

Keywords

cutaneous blastomycosis opportunistic infection SLE

Get full access to this article

View all access options for this article.

References

1 Kuhn A Sticherling M Bonsmann G . Clinical manifestations of cutaneous lupus erythematosus. J Dtsch Dermatol Ges 2007; 5: 1124–1137.

2 Kauffman CA . Endemic mycoses: blastomycosis, histoplasmosis, and sporotrichosis. Infect Dis Clin North Am 2006; 20: 645–662.

3 Furcolow ML Chick EW Busey JF Menges RW . Prevalence and incidence studies of human and canine blastomycosis. 1. Cases in the United States, 1885–1968. Am Rev Respir Dis 1970; 102: 60–67.

4 Lemos LB Guo M Baliga M . Blastomycosis: organ involvement and etiologic diagnosis. A review of 123 patients from Mississippi. Ann Diagn Pathol 2000; 4: 391–406.

5 Pappas PG Threlkeld MG Bedsole GD Cleveland KO Gelfand MS Dismukes WE . Blastomycosis in immunocompromised patients. Medicine (Baltimore) 1993; 72: 311–325.

6 Pappas PG . Blastomycosis in the immunocompromised patient. Semin Respir Infect 1997; 12: 243–251.

7 Mohazab HR Langer BG Ramsey RG . Intracranial blastomycosis presenting as a suprasellar mass: MR findings. J Comput Assist Tomogr 1997; 21: 845–847.

8 Sieving RR Kauffman CA Watanakukorn C . Deep fungal infection in systemic lupus erythematosus. Three cases reported, literature reviewed. J Rheumatol 1975; 2: 61–72.

9 Chen HS Tsai WP Leu HS Ho HH Liou LB . Invasive fungal infection in systemic lupus erythematosus: an analysis of 15 cases and a literature review. Rheumatology (Oxford) 2007; 46: 539–544.

10.

10 Wages DS Wear LD . Acid-fastness of fungi in blastomycosis and histoplasmosis. Arch Pathol Lab Med 1982; 106: 440–441.

11.

11 Chapman SW Dismukes WE Proia LA . Infectious Diseases Society of America. Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2008; 46: 1801–1812.