A 24-year-old male presented with a 2-year history of an insidiously expanding lesion to his left lateral thigh (Panel A) and widespread pink annular scaly plaques with central hypopigmentation to torso and extremities. He had not been seen for the lesion or rash until being hospitalized for a new cough and painful erythematous joint of right knee. Arthrocentesis showed 21,126 nucleated cells/uL with 98% neutrophils, and MRI demonstrated a 1.5 x 2.4 x 6.7cm right femoral bone abscess with concomitant large joint effusion and enhancing synovitis (Panel B). Orthopedics was consulted with subsequent right knee arthrotomy, synovectomy, and partial excision and debridement of right distal femur. Two separate lesion punch biopsies, joint effusion analysis, and bone abscess evaluation all demonstrated budding yeast (Panel C).
Infectious disease started empiric voriconazole. When cultures were confirmed as Blastomycosis dermatitidis, treatment was changed to itraconazole. At 4-week follow-up, there was healthy remodeling and wound contracture of thigh lesion.