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Semin Respir Crit Care Med 2011; 32(6): 745-753
DOI: 10.1055/s-0031-1295722
© Thieme Medical Publishers

Pulmonary Blastomycosis

J. Ryan Bariola1 , 2 , Keyur S. Vyas1 , 2
  • 1Division of Infectious Diseases, University of Arkansas for Medical Sciences, Little Rock, Arkansas
  • 2Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
Further Information

Publication History

Publication Date:
13 December 2011 (online)

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ABSTRACT

Blastomyces dermatitidis is acquired in almost all cases via inhalation, and pulmonary disease is the most frequent clinical manifestation of blastomycosis. Pulmonary disease can range from asymptomatic infection to rapidly severe and fatal disease. Most cases will present as pneumonia, either acute or chronic, or as a lung mass. In rare cases pulmonary blastomycosis is associated with the acute respiratory distress syndrome. Blastomycosis can present as isolated pulmonary disease or along with coexisting extrapulmonary disease that usually will involve the skin, bony structures, genitourinary tract, or central nervous system. Diagnosis is largely based on isolation of the organism via culture or visualization of the organism in clinical specimens. Detection of urinary Blastomyces antigen is a recent addition to diagnostic options. Itraconazole is the drug of choice for most forms of the disease; amphotericin B is reserved for the more severe forms. Newer azoles such as voriconazole and posaconazole have a limited role in the treatment of pulmonary blastomycosis.

KEYWORDS

Blastomycosis - Blastomyces dermatitidis - pneumonia - fungal pneumonia - pulmonary infection

REFERENCES

  • 1 Gilchrist T C, Stokes W R. A case of pseudo-lupus vulgaris caused by a Blastomyces.  J Exp Med. 1898;  3 (1) 53-78
    Google Scholar
  • 2 Witorsch P, Utz J P. North American blastomycosis: a study of 40 patients.  Medicine (Baltimore). 1968;  47 (3) 169-200
    Google Scholar
  • 3 Sarosi G A, Davies S F. Blastomycosis.  Am Rev Respir Dis. 1979;  120 (4) 911-938
    Google Scholar
  • 4 Nemecek J C, Wüthrich M, Klein B S. Global control of dimorphism and virulence in fungi.  Science. 2006;  312 (5773) 583-588
    Google Scholar
  • 5 Drutz D J, Frey C L. Intracellular and extracellular defenses of human phagocytes against Blastomyces dermatitidis conidia and yeasts.  J Lab Clin Med. 1985;  105 (6) 737-750
    Google Scholar
  • 6 Sugar A M, Picard M. Macrophage- and oxidant-mediated inhibition of the ability of live Blastomyces dermatitidis conidia to transform to the pathogenic yeast phase: implications for the pathogenesis of dimorphic fungal infections.  J Infect Dis. 1991;  163 (2) 371-375
    Google Scholar
  • 7 Rocco N M, Carmen J C, Klein B S. Blastomyces dermatitidis yeast cells inhibit nitric oxide production by alveolar macrophage inducible nitric oxide synthase.  Infect Immun. 2011;  79 (6) 2385-2395
    Google Scholar
  • 8 Hogan L H, Klein B S. Altered expression of surface alpha-1,3-glucan in genetically related strains of Blastomyces dermatitidis that differ in virulence.  Infect Immun. 1994;  62 (8) 3543-3546
    Google Scholar
  • 9 Newman S L, Chaturvedi S, Klein B S. The WI-1 antigen of Blastomyces dermatitidis yeasts mediates binding to human macrophage CD11b/CD18 (CR3) and CD14.  J Immunol. 1995;  154 (2) 753-761
    Google Scholar
  • 10 Brandhorst T T, Wüthrich M, Warner T, Klein B. Targeted gene disruption reveals an adhesin indispensable for pathogenicity of Blastomyces dermatitidis.  J Exp Med. 1999;  189 (8) 1207-1216
    Google Scholar
  • 11 Finkel-Jimenez B, Wüthrich M, Brandhorst T, Klein B S. The WI-1 adhesin blocks phagocyte TNF-alpha production, imparting pathogenicity on Blastomyces dermatitidis.  J Immunol. 2001;  166 (4) 2665-2673
    Google Scholar
  • 12 Finkel-Jimenez B, Wüthrich M, Klein B S. BAD1, an essential virulence factor of Blastomyces dermatitidis, suppresses host TNF-alpha production through TGF-beta-dependent and -independent mechanisms.  J Immunol. 2002;  168 (11) 5746-5755
    Google Scholar
  • 13 Zhang M X, Brandhorst T T, Kozel T R, Klein B S. Role of glucan and surface protein BAD1 in complement activation by Blastomyces dermatitidis yeast.  Infect Immun. 2001;  69 (12) 7559-7564
    Google Scholar
  • 14 Bradsher R W, Chapman S W, Pappas P G. Blastomycosis.  Infect Dis Clin North Am. 2003;  17 (1) 21-40 vii
    Google Scholar
  • 15 Baumgardner D J, Steber D, Glazier R et al.. Geographic information system analysis of blastomycosis in northern Wisconsin, USA: waterways and soil.  Med Mycol. 2005;  43 (2) 117-125
    Google Scholar
  • 16 Dworkin M S, Duckro A N, Proia L, Semel J D, Huhn G. The epidemiology of blastomycosis in Illinois and factors associated with death.  Clin Infect Dis. 2005;  41 (12) e107-e111
    Google Scholar
  • 17 Morris S K, Brophy J, Richardson S E et al.. Blastomycosis in Ontario, 1994-2003.  Emerg Infect Dis. 2006;  12 (2) 274-279
    Google Scholar
  • 18 Centers for Disease Control and Prevention . Blastomycosis—Wisconsin, 1986–1995.  MMWR Morb Mortal Wkly Rep. 1996;  45 601-603
    Google Scholar
  • 19 Chu J H, Feudtner C, Heydon K, Walsh T J, Zaoutis T E. Hospitalizations for endemic mycoses: a population-based national study.  Clin Infect Dis. 2006;  42 (6) 822-825
    Google Scholar
  • 20 Klein B S, Vergeront J M, Weeks R J et al.. Isolation of Blastomyces dermatitidis in soil associated with a large outbreak of blastomycosis in Wisconsin.  N Engl J Med. 1986;  314 (9) 529-534
    Google Scholar
  • 21 Klein B S, Vergeront J M, DiSalvo A F, Kaufman L, Davis J P. Two outbreaks of blastomycosis along rivers in Wisconsin. Isolation of Blastomyces dermatitidis from riverbank soil and evidence of its transmission along waterways.  Am Rev Respir Dis. 1987;  136 (6) 1333-1338
    Google Scholar
  • 22 Proctor M E, Klein B S, Jones J M, Davis J P. Cluster of pulmonary blastomycosis in a rural community: evidence for multiple high-risk environmental foci following a sustained period of diminished precipitation.  Mycopathologia. 2002;  153 (3) 113-120
    Google Scholar
  • 23 Pfister J R, Archer J R, Hersil S et al.. Non-rural point source blastomycosis outbreak near a yard waste collection site.  Clin Med Res. 2011;  9 (2) 57-65
    Google Scholar
  • 24 Carlos W G, Rose A S, Wheat L J et al.. Blastomycosis in Indiana: digging up more cases.  Chest. 2010;  138 (6) 1377-1382
    Google Scholar
  • 25 Denton J F, Disalvo A F. Isolation of Blastomyces dermatitidis from natural sites in Augusta, Georgia.  Am J Trop Med Hyg. 1964;  13 716-722
    Google Scholar
  • 26 Bakerspigel A, Kane J, Schaus D. Isolation of Blastomyces dermatitidis from an earthen floor in southwestern Ontario, Canada.  J Clin Microbiol. 1986;  24 (5) 890-891
    Google Scholar
  • 27 Burgess J W, Schwan W R, Volk T J. PCR-based detection of DNA from the human pathogen Blastomyces dermatitidis from natural soil samples.  Med Mycol. 2006;  44 (8) 741-748
    Google Scholar
  • 28 Dwight P J, Naus M, Sarsfield P, Limerick B. An outbreak of human blastomycosis: the epidemiology of blastomycosis in the Kenora catchment region of Ontario, Canada.  Can Commun Dis Rep. 2000;  26 (10) 82-91
    Google Scholar
  • 29 Vaaler A K, Bradsher R W, Davies S F. Evidence of subclinical blastomycosis in forestry workers in northern Minnesota and northern Wisconsin.  Am J Med. 1990;  89 (4) 470-476
    Google Scholar
  • 30 Landis F B, Varkey B. Late relapse of pulmonary blastomycosis after adequate treatment with amphotericin B. Case report.  Am Rev Respir Dis. 1976;  113 (1) 77-81
    Google Scholar
  • 31 Lemos L B, Baliga M, Guo M. Blastomycosis: the great pretender can also be an opportunist: initial clinical diagnosis and underlying diseases in 123 patients.  Ann Diagn Pathol. 2002;  6 (3) 194-203
    Google Scholar
  • 32 Pappas P G, Pottage J C, Powderly W G et al.. Blastomycosis in patients with the acquired immunodeficiency syndrome.  Ann Intern Med. 1992;  116 (10) 847-853
    Google Scholar
  • 33 Pappas P G. Blastomycosis in the immunocompromised patient.  Semin Respir Infect. 1997;  12 (3) 243-251
    Google Scholar
  • 34 Gauthier G M, Safdar N, Klein B S, Andes D R. Blastomycosis in solid organ transplant recipients.  Transpl Infect Dis. 2007;  9 (4) 310-317
    Google Scholar
  • 35 Harris J R, Blaney D D, Lindsley M D et al.. Blastomycosis in man after kinkajou bite.  Emerg Infect Dis. 2011;  17 (2) 268-270
    Google Scholar
  • 36 Farber E R, Leahy M S, Meadows T R. Endometrial blastomycosis acquired by sexual contact.  Obstet Gynecol. 1968;  32 (2) 195-199
    Google Scholar
  • 37 Maxson S, Miller S F, Tryka F, Schutze G E. Perinatal blastomycosis: a review.  Pediatr Infect Dis J. 1992;  11 760-763
    Google Scholar
  • 38 Bradsher R W, Rice D C, Abernathy R S. Ketoconazole therapy for endemic blastomycosis.  Ann Intern Med. 1985;  103 (6 Pt 1) 872-879
    Google Scholar
  • 39 Halvorsen R A, Duncan J D, Merten D F, Gallis H A, Putman C E. Pulmonary blastomycosis: radiologic manifestations.  Radiology. 1984;  150 (1) 1-5
    Google Scholar
  • 40 Sheflin J R, Campbell J A, Thompson G P. Pulmonary blastomycosis: findings on chest radiographs in 63 patients.  AJR Am J Roentgenol. 1990;  154 (6) 1177-1180
    Google Scholar
  • 41 Brown L R, Swensen S J, Van Scoy R E, Prakash U B, Coles D T, Colby T V. Roentgenologic features of pulmonary blastomycosis.  Mayo Clin Proc. 1991;  66 (1) 29-38
    Google Scholar
  • 42 Rabinowitz J G, Busch J B, Buttram W R. Pulmonary manifestations of blastomycosis: radiological support of a new concept.  Radiology. 1976;  120 (1) 25-32
    Google Scholar
  • 43 Bariola J R, Hage C A, Durkin M et al.. Detection of Blastomyces dermatitidis antigen in patients with newly diagnosed blastomycosis.  Diagn Microbiol Infect Dis. 2011;  69 (2) 187-191
    Google Scholar
  • 44 Hawley C, Felson B. Roentgen aspects of intrathoracic blastomycosis.  Am J Roentgenol Radium Ther Nucl Med. 1956;  75 (4) 751-757
    Google Scholar
  • 45 O’Marro S D, Varkey B. Unexpected recovery of Blastomyces dermatitidis from an anaerobic pleural empyema.  Am J Med. 1989;  86 (6 Pt 2) 833
    Google Scholar
  • 46 Arora N S, Oblinger M J, Feldman P S. Chronic pleural blastomycosis with hyperprolactinemia, galactorrhea, and amenorrhea.  Am Rev Respir Dis. 1979;  120 (2) 451-455
    Google Scholar
  • 47 Griffith J E, Campbell G D. Acute miliary blastomycosis presenting as fluminating respiratory failure.  Chest. 1979;  75 (5) 630-632
    Google Scholar
  • 48 Berger R, Kraman S. Acute miliary blastomycosis after ‘short-course’ corticosteroid treatment.  Arch Intern Med. 1981;  141 (9) 1223-1225
    Google Scholar
  • 49 Stelling C B, Woodring J H, Rehm S R, Hopper D W, Noble R C. Miliary pulmonary blastomycosis.  Radiology. 1984;  150 (1) 7-13
    Google Scholar
  • 50 Evans M E, Haynes J B, Atkinson J B, Delvaux Jr T C, Kaiser A B. Blastomyces dermatitidis and the adult respiratory distress syndrome: case reports and review of the literature.  Am Rev Respir Dis. 1982;  126 (6) 1099-1102
    Google Scholar
  • 51 Thiele J S, Buechner H A, Deshotels Jr S J. Blastomycosis and the adult respiratory distress syndrome.  J La State Med Soc. 1984;  136 (11) 38-40
    Google Scholar
  • 52 Skillrud D M, Douglas W W. Survival in adult respiratory distress syndrome caused by blastomycosis infection.  Mayo Clin Proc. 1985;  60 (4) 266-269
    Google Scholar
  • 53 Meyer K C, McManus E J, Maki D G. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome.  N Engl J Med. 1993;  329 (17) 1231-1236
    Google Scholar
  • 54 Mukkamala R, Mehta J B, Myers J W, Cole C P. Pulmonary blastomycosis with acute respiratory failure as predominant clinical feature.  South Med J. 1997;  90 (8) 847-850
    Google Scholar
  • 55 Lemos L B, Baliga M, Guo M. Acute respiratory distress syndrome and blastomycosis: presentation of nine cases and review of the literature.  Ann Diagn Pathol. 2001;  5 (1) 1-9
    Google Scholar
  • 56 Lemos L B, Guo M, Baliga M. Blastomycosis: organ involvement and etiologic diagnosis. A review of 123 patients from Mississippi.  Ann Diagn Pathol. 2000;  4 (6) 391-406
    Google Scholar
  • 57 Martynowicz M A, Prakash U B. Pulmonary blastomycosis: an appraisal of diagnostic techniques.  Chest. 2002;  121 (3) 768-773
    Google Scholar
  • 58 Hage C A, Davis T E, Fuller D et al.. Diagnosis of histoplasmosis by antigen detection in BAL fluid.  Chest. 2010;  137 (3) 623-628
    Google Scholar
  • 59 Patel A J, Gattuso P, Reddy V B. Diagnosis of blastomycosis in surgical pathology and cytopathology: correlation with microbiologic culture.  Am J Surg Pathol. 2010;  34 (2) 256-261
    Google Scholar
  • 60 Durkin M, Witt J, Lemonte A, Wheat B, Connolly P. Antigen assay with the potential to aid in diagnosis of blastomycosis.  J Clin Microbiol. 2004;  42 (10) 4873-4875
    Google Scholar
  • 61 Turner S, Kaufman L. Immunodiagnosis of blastomycosis.  Semin Respir Infect. 1986;  1 (1) 22-28
    Google Scholar
  • 62 Bradsher R W, Pappas P G. Detection of specific antibodies in human blastomycosis by enzyme immunoassay.  South Med J. 1995;  88 (12) 1256-1259
    Google Scholar
  • 63 Klein B S, Vergeront J M, Kaufman L et al.. Serological tests for blastomycosis: assessments during a large point-source outbreak in Wisconsin.  J Infect Dis. 1987;  155 (2) 262-268
    Google Scholar
  • 64 Klein B S, Jones J M. Isolation, purification, and radiolabeling of a novel 120-kD surface protein on Blastomyces dermatitidis yeasts to detect antibody in infected patients.  J Clin Invest. 1990;  85 (1) 152-161
    Google Scholar
  • 65 Soufleris A J, Klein B S, Courtney B T, Proctor M E, Jones J M. Utility of anti-WI-1 serological testing in the diagnosis of blastomycosis in Wisconsin residents.  Clin Infect Dis. 1994;  19 (1) 87-92
    Google Scholar
  • 66 Sarosi G A, Davies S F, Phillips J R. Self-limited blastomycosis: a report of 39 cases.  Semin Respir Infect. 1986;  1 (1) 40-44
    Google Scholar
  • 67 Recht L D, Philips J R, Eckman M R, Sarosi G A. Self-limited blastomycosis: a report of thirteen cases.  Am Rev Respir Dis. 1979;  120 (5) 1109-1112
    Google Scholar
  • 68 Saccente M, Woods G L. Clinical and laboratory update on blastomycosis.  Clin Microbiol Rev. 2010;  23 (2) 367-381
    Google Scholar
  • 69 Chapman S W, Dismukes W E, Proia L A Infectious Diseases Society of America et al. Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America.  Clin Infect Dis. 2008;  46 (12) 1801-1812
    Google Scholar
  • 70 Harrell E R, Curtis A C. The treatment of North American blastomycosis with amphotericin B.  AMA Arch Derm. 1957;  76 (5) 561-568 discussion 568-569
    Google Scholar
  • 71 Busey J F. Blastomycosis: a review of 198 collected cases in VA hospitals.  Am Rev Respir Dis. 1964;  89 659-672
    Google Scholar
  • 72 Lockwood W R, Allison Jr F, Batson B E, Busey J F. The treatment of North American blastomycosis. Ten years’ experience.  Am Rev Respir Dis. 1969;  100 (3) 314-320
    Google Scholar
  • 73 Parker J D, Doto I L, Tosh F E. A decade of experience with blastomycosis and its treatment with amphotericin B. A National Communicable Disease Center Cooperative Mycoses Study.  Am Rev Respir Dis. 1969;  99 (6) 895-902
    Google Scholar
  • 74 Seabury J H, Dascomb H E. Results of the treatment of systemic mycoses.  JAMA. 1964;  188 509-513
    Google Scholar
  • 75 Abernathy R S. Amphotericin therapy of North American blastomycosis.  Antimicrob Agents Chemother (Bethesda). 1966;  6 208-211
    Google Scholar
  • 76 Busey J F. Blastomycosis, III: A comparative study of 2-hydroxystilbamidine and amphotericin B therapy.  Am Rev Respir Dis. 1972;  105 (5) 812-818
    Google Scholar
  • 77 Dismukes W E, Stamm A M, Graybill J R et al.. Treatment of systemic mycoses with ketoconazole: emphasis on toxicity and clinical response in 52 patients. National Institute of Allergy and Infectious Diseases collaborative antifungal study.  Ann Intern Med. 1983;  98 (1) 13-20
    Google Scholar
  • 78 National Institute of Allergy and Infectious Diseases Mycoses Study Group . Treatment of blastomycosis and histoplasmosis with ketoconazole: results of a prospective randomized clinical trial.  Ann Intern Med. 1985;  103 (6 Pt 1) 861-872
    Google Scholar
  • 79 Pitrak D L, Andersen B R. Cerebral blastomycoma after ketoconazole therapy for respiratory tract blastomycosis.  Am J Med. 1989;  86 (6 Pt 1) 713-714
    Google Scholar
  • 80 Dismukes W E, Bradsher Jr R W, Cloud G C NIAID Mycoses Study Group et al. Itraconazole therapy for blastomycosis and histoplasmosis.  Am J Med. 1992;  93 (5) 489-497
    Google Scholar
  • 81 Bradsher R W. Blastomycosis.  Clin Infect Dis. 1992;  14 (Suppl 1) S82-S90
    Google Scholar
  • 82 Dodds Ashley E, Lewis R, Lewis J et al.. Pharmacology of systemic antifungal agents.  Clin Infect Dis. 2006;  43 (Suppl 1) S28-S39
    Google Scholar
  • 83 Pappas P G, Bradsher R W, Chapman S W The National Institute of Allergy and Infectious Diseases Mycoses Study Group et al. Treatment of blastomycosis with fluconazole: a pilot study.  Clin Infect Dis. 1995;  20 (2) 267-271
    Google Scholar
  • 84 Pappas P G, Bradsher R W, Kauffman C A The National Institute of Allergy and Infectious Diseases Mycoses Study Group et al. Treatment of blastomycosis with higher doses of fluconazole.  Clin Infect Dis. 1997;  25 (2) 200-205
    Google Scholar
  • 85 Li R K, Ciblak M A, Nordoff N, Pasarell L, Warnock D W, McGinnis M R. In vitro activities of voriconazole, itraconazole, and amphotericin B against Blastomyces dermatitidis, Coccidioides immitis, and Histoplasma capsulatum.  Antimicrob Agents Chemother. 2000;  44 (6) 1734-1736
    Google Scholar
  • 86 Sugar A M, Liu X P. Efficacy of voriconazole in treatment of murine pulmonary blastomycosis.  Antimicrob Agents Chemother. 2001;  45 (2) 601-604
    Google Scholar
  • 87 Freifeld A G, Bariola J R, Andes D. The role of second-generation antifungal triazoles for treatment of the endemic mycoses.  Curr Infect Dis Rep. 2010;  12 (6) 471-478
    Google Scholar
  • 88 Bakleh M, Aksamit A J, Tleyjeh I M, Marshall W F. Successful treatment of cerebral blastomycosis with voriconazole.  Clin Infect Dis. 2005;  40 (9) e69-e71
    Google Scholar
  • 89 Borgia S M, Fuller J D, Sarabia A, El-Helou P. Cerebral blastomycosis: a case series incorporating voriconazole in the treatment regimen.  Med Mycol. 2006;  44 (7) 659-664
    Google Scholar
  • 90 Panicker J, Walsh T, Kamani N. Recurrent central nervous system blastomycosis in an immunocompetent child treated successfully with sequential liposomal amphotericin B and voriconazole.  Pediatr Infect Dis J. 2006;  25 (4) 377-379
    Google Scholar
  • 91 Freifeld A, Proia L, Andes D et al.. Voriconazole use for endemic fungal infections.  Antimicrob Agents Chemother. 2009;  53 (4) 1648-1651
    Google Scholar
  • 92 Bariola J R, Perry P, Pappas P G et al.. Blastomycosis of the central nervous system: a multicenter review of diagnosis and treatment in the modern era.  Clin Infect Dis. 2010;  50 (6) 797-804
    Google Scholar
  • 93 Sabatelli F, Patel R, Mann P A et al.. In vitro activities of posaconazole, fluconazole, itraconazole, voriconazole, and amphotericin B against a large collection of clinically important molds and yeasts.  Antimicrob Agents Chemother. 2006;  50 (6) 2009-2015
    Google Scholar
  • 94 Sugar A M, Liu X P. In vitro and in vivo activities of SCH 56592 against Blastomyces dermatitidis.  Antimicrob Agents Chemother. 1996;  40 (5) 1314-1316
    Google Scholar
  • 95 Zhanel G G, Karlowsky J A, Harding G A et al.. In vitro activity of a new semisynthetic echinocandin, LY-303366, against systemic isolates of Candida species, Cryptococcus neoformans, Blastomyces dermatitidis, and Aspergillus species.  Antimicrob Agents Chemother. 1997;  41 (4) 863-865
    Google Scholar
  • 96 Espinel-Ingroff A. Comparison of in vitro activities of the new triazole SCH56592 and the echinocandins MK-0991 (L-743,872) and LY303366 against opportunistic filamentous and dimorphic fungi and yeasts.  J Clin Microbiol. 1998;  36 (10) 2950-2956
    Google Scholar
  • 97 Vasquez J E, Mehta J B, Agrawal R, Sarubbi F A. Blastomycosis in northeast Tennessee.  Chest. 1998;  114 (2) 436-443
    Google Scholar
  • 98 Lahm T, Neese S, Thornburg A T, Ober M D, Sarosi G A, Hage C A. Corticosteroids for blastomycosis-induced ARDS: a report of two patients and review of the literature.  Chest. 2008;  133 (6) 1478-1480
    Google Scholar
  • 99 Plamondon M, Lamontagne F, Allard C, Pépin J. Corticosteroids as adjunctive therapy in severe blastomycosis-induced acute respiratory distress syndrome in an immunosuppressed patient.  Clin Infect Dis. 2010;  51 (1) e1-e3
    Google Scholar
  • 100 Wüthrich M, Chang W L, Klein B S. Immunogenicity and protective efficacy of the WI-1 adhesin of Blastomyces dermatitidis.  Infect Immun. 1998;  66 (11) 5443-5449
    Google Scholar
  • 101 Klein B S. Molecular basis of pathogenicity in Blastomyces dermatitidis: the importance of adhesion.  Curr Opin Microbiol. 2000;  3 (4) 339-343
    Google Scholar
  • 102 Wüthrich M, Krajaejun T, Shearn-Bochsler V et al.. Safety, tolerability, and immunogenicity of a recombinant, genetically engineered, live-attenuated vaccine against canine blastomycosis.  Clin Vaccine Immunol. 2011;  18 (5) 783-789
    Google Scholar

J. Ryan BariolaM.D. 

Division of Infectious Diseases, University of Arkansas for Medical Sciences

4301 W. Markham St., Mail Slot #639, Little Rock, AR 72205

Email: bariolajeremyr@uams.edu