WEBVTT - Ep 125 Blastomycosis: How fungus became amongus 0:00:00.240 --> 0:00:03.559 The case was under the care of doctor During in Philadelphia, 0:00:03.920 --> 0:00:07.440 by whom it was diagnosed clinically as a typical example 0:00:07.560 --> 0:00:12.360 of chronic scrophuloderma. By his courtesy, I received a portion 0:00:12.480 --> 0:00:16.079 of the disease tissues, but was unable to demonstrate the 0:00:16.160 --> 0:00:20.080 presence in it of the tubercule bacillus. In the course 0:00:20.079 --> 0:00:25.400 of the examination, however, numerous curious bodies were found, distributed 0:00:25.440 --> 0:00:29.440 here and there throughout all the sections. They presented the 0:00:29.480 --> 0:00:33.200 appearance of parasites and the discovery rendered the case one 0:00:33.240 --> 0:00:37.479 of peculiar interest. Unfortunately, the matter could not be followed 0:00:37.479 --> 0:00:40.120 out as closely as could have been desired, as no 0:00:40.240 --> 0:00:43.760 more material could be obtained, the patient having been operated 0:00:43.840 --> 0:00:47.960 upon and the whole lesion having been removed. Three months 0:00:48.000 --> 0:00:52.120 after our first brief report, Otto Bousse published a case 0:00:52.280 --> 0:00:56.800 in which apparently similar bodies were demonstrated. Still later, other 0:00:56.880 --> 0:01:01.360 observers have found lesions in animals, horse, guinea pigs, etc. 0:01:02.200 --> 0:01:05.800 In Which very similar bodies have played a pathogenic role, 0:01:06.360 --> 0:01:09.120 but the present appears to be the first recorded case 0:01:09.200 --> 0:01:13.000 in which they have given rise to pathological processes in man. 0:01:13.640 --> 0:01:17.600 In reporting the case before the American Dermatological Society. I 0:01:17.720 --> 0:01:21.600 expressed the opinion that these bodies, in all probability would 0:01:21.640 --> 0:01:25.000 be found to belong to plant rather than to animal life, 0:01:25.600 --> 0:01:30.240 and further examination appeared to verify the conclusion that they 0:01:30.319 --> 0:02:00.240 might be classed as blastomycedes. 0:02:17.639 --> 0:02:21.760 I'm so curious to see where they went after that, I. 0:02:21.720 --> 0:02:29.000 Mean, blastamycosis. Maybe they named They named it eventually. So 0:02:29.200 --> 0:02:34.480 that is from TC Gilcrest eighteen ninety six in a 0:02:35.080 --> 0:02:40.160 report titled a Case of Blastomycetic Dermatitis in Man and 0:02:40.240 --> 0:02:40.680 it was. 0:02:41.160 --> 0:02:42.160 The first. 0:02:43.360 --> 0:02:47.959 Description clinical description of what we now know is blastomycosis. 0:02:48.160 --> 0:02:48.680 I love it. 0:02:49.040 --> 0:02:52.799 Yeah, you know, just go to the OG source. 0:02:52.720 --> 0:02:57.080 Straight to the source, why not. Yeah. 0:02:57.160 --> 0:03:00.480 Hi, I'm Aaron Welsh and I'm Erin allman up and 0:03:00.639 --> 0:03:03.160 this is this podcast will kill you today. 0:03:03.200 --> 0:03:04.600 We're talking fungus. 0:03:05.040 --> 0:03:08.400 We are uh huh. We haven't done this often, not 0:03:08.680 --> 0:03:09.240 in a while. 0:03:09.440 --> 0:03:09.840 Yeah. 0:03:09.919 --> 0:03:12.440 Yeah, I'm excited by that, me too. 0:03:14.919 --> 0:03:15.959 It's gonna be a good one. 0:03:16.000 --> 0:03:22.560 And I think that blastomycosis is strange. And I am 0:03:22.760 --> 0:03:26.519 especially curious about the current research. 0:03:27.080 --> 0:03:34.920 Oh yeah, yeah, me too. I am excited about it 0:03:34.960 --> 0:03:38.240 because we don't yeah, we haven't covered a lot of 0:03:38.440 --> 0:03:40.480 fung guy, I don't feel like they get enough attention. 0:03:41.920 --> 0:03:45.240 They don't, and many papers that I read started out 0:03:45.240 --> 0:03:49.320 that way. Yeah, medical micology is an overlooked field. It 0:03:49.400 --> 0:03:53.640 really is, despite the large burden of disease that agree, 0:03:53.680 --> 0:03:56.320 pathogenic fungi, whatever, et cetera. 0:03:57.000 --> 0:03:59.640 So let's just fill in that etcetera today, shall we hear? 0:04:00.720 --> 0:04:04.480 Let's do it, but first, it's quarantiney time. 0:04:05.440 --> 0:04:09.000 Yes, yes, yes, my favorite time. What are we drinking 0:04:09.040 --> 0:04:09.480 this week? 0:04:09.640 --> 0:04:12.120 We're drinking Blast from the Past. 0:04:12.720 --> 0:04:16.400 I mean, you know, there were so many Quarantini name 0:04:16.480 --> 0:04:19.719 options with this one blast. I'm sure that our title 0:04:19.760 --> 0:04:23.040 will have Blast in it at some point or another. 0:04:23.480 --> 0:04:24.200 We'll find out. 0:04:24.480 --> 0:04:27.160 Yeah, but I like blash in the past too, because, 0:04:27.400 --> 0:04:31.960 as you'll hear in the history section, I'm going kind 0:04:31.960 --> 0:04:34.640 of way way, way way back. 0:04:34.880 --> 0:04:37.120 I love it and I'm excited about it. Are we 0:04:37.160 --> 0:04:38.640 going in deep time again? Aaron? 0:04:40.480 --> 0:04:42.840 I don't know what the exact definition of deep time is, 0:04:42.839 --> 0:04:47.200 but it feels pretty deep. Okay, let's get into the recipe. 0:04:47.440 --> 0:04:51.120 Sow. Oh yeah, I really do. Un what's been a 0:04:51.160 --> 0:04:54.600 blast to the past, Aarin? It is so delicious. 0:04:55.040 --> 0:04:57.520 It's kind of a take on like a bourbon smash, 0:04:57.680 --> 0:05:01.880 but instead of bourbon, it's right whiskey, and we're doing 0:05:01.960 --> 0:05:07.040 peaches and ginger beer of course, lemon juice and basil. 0:05:07.480 --> 0:05:11.320 Oh so ym it's really refreshing and delightful. 0:05:11.839 --> 0:05:14.359 You can find the full recipe for that quarantine and 0:05:14.600 --> 0:05:17.520 our non alcoholic plusy Brita on our website, this podcast 0:05:17.560 --> 0:05:20.360 with Killy dot com, and our social media. 0:05:20.680 --> 0:05:24.719 Now for website stuff, there's lots of things. I have 0:05:24.800 --> 0:05:28.600 the website right here, fortunately, so let's just go through 0:05:28.640 --> 0:05:33.000 some of these tabs. Well, we've got the sources for 0:05:33.080 --> 0:05:35.599 each and every one of our episodes. We've got links 0:05:35.640 --> 0:05:38.719 to our bookshop dot org, affiliate account, our Goodreads list, 0:05:39.279 --> 0:05:42.400 our merch some pretty sweet merch there. We've got links 0:05:42.400 --> 0:05:49.599 to music by Bloodmobile, Patreon, submit your first hand account, form, transcripts, 0:05:50.400 --> 0:05:53.120 and stuff about us that we probably should update. 0:05:53.360 --> 0:05:58.800 We probably should actually yeah someday. Okay, then any other 0:05:58.880 --> 0:06:00.720 business that we should deal with. 0:06:01.160 --> 0:06:03.279 I don't think so. I think that we should just 0:06:03.480 --> 0:06:06.680 dive right into the episode. 0:06:06.920 --> 0:06:09.280 Okay, let's take a quick break and get into it. 0:06:35.360 --> 0:06:40.000 Blastomycosis is the name of the disease caused by the 0:06:40.040 --> 0:06:45.560 fungus blastomics dermatitidis, which I looked up how to say, 0:06:45.600 --> 0:06:48.040 like a hundred times, so hopefully that's right. 0:06:48.360 --> 0:06:50.520 I mean the spelling of it. I was like, this 0:06:50.640 --> 0:06:53.240 must be a typo. I kept being like, there are 0:06:53.240 --> 0:06:55.000 way too many eyes and teas. 0:06:54.839 --> 0:07:00.000 And your eyes and t's and d's and eyes blastomics dermatititis. 0:07:00.080 --> 0:07:06.240 The other major species is Blastomyces gilchristii, which you said 0:07:06.279 --> 0:07:10.640 that that first hand account came from doctor Gilchrist himself. 0:07:10.760 --> 0:07:19.880 Sure did, Okay, there's a story there, history over, and 0:07:20.200 --> 0:07:25.200 blastomycosis is a disease of so much more than just humans. 0:07:26.280 --> 0:07:28.920 This is a fungus that has been found causing disease 0:07:29.080 --> 0:07:34.080 and death in humans, but also canids, including wolves and coyotes. 0:07:34.680 --> 0:07:36.920 And from what I read, it's estimated that in like 0:07:37.000 --> 0:07:40.640 our domestic dogs, infection rates are likely eight to ten 0:07:40.680 --> 0:07:44.320 times higher than what they are in humans, so we'll 0:07:44.320 --> 0:07:52.480 come back to that eventually, but also in sea lions, dolphins, ferrets, lions, bears, lemurs, bats. 0:07:53.160 --> 0:07:54.320 This thing has been around the block. 0:07:55.040 --> 0:07:58.800 It's fascinating. I was gonna say it's cool, but. 0:07:58.920 --> 0:08:03.080 Like ooh ooh, interesting choice of words, because it's a 0:08:03.160 --> 0:08:05.720 thermally dimorphic fungus. 0:08:06.400 --> 0:08:09.720 Which I had to look up what that was. Yeah, 0:08:09.760 --> 0:08:11.880 and now I'm like, there's a whole world of these 0:08:12.000 --> 0:08:12.960 Why did this evolve? 0:08:13.040 --> 0:08:16.080 This is fascin So this is a characteristic of some 0:08:16.120 --> 0:08:20.640 of the fungi in the phylum Askomycoda, And this basically 0:08:20.720 --> 0:08:26.760 means that these fungi exist in different states or different forms, 0:08:26.880 --> 0:08:31.400 depending on the temperature, the ambient temperature and other factors 0:08:31.400 --> 0:08:36.480 as well. But in the environment, Blastomyces exists as a 0:08:36.559 --> 0:08:39.439 mold like the mold on your bread or your cheese, 0:08:40.040 --> 0:08:42.599 kind of if you looked at it under the microscope, 0:08:42.600 --> 0:08:45.880 it would have these long filaments that are called hyphi. 0:08:46.760 --> 0:08:52.600 And this form, this mold form reproduces asexually by making 0:08:52.640 --> 0:08:56.520 these things called canidia, which are spores that can go 0:08:56.559 --> 0:09:01.200 out and disperse long distances. The way that we get 0:09:01.200 --> 0:09:06.760 exposed to Blastomyces is via these spores, the canidia, sometimes 0:09:06.760 --> 0:09:09.000 directly from the high fee if like little bits get 0:09:09.120 --> 0:09:13.720 broken off and we inhale them when they're aerosolized with 0:09:13.800 --> 0:09:18.760 soil particles, or less commonly, we can get inoculated with 0:09:18.840 --> 0:09:21.920 the spores or the high feet in our skin. If 0:09:22.000 --> 0:09:24.280 we get a scratch from say like a plant or 0:09:24.320 --> 0:09:29.360 something ooh. And then what happens is that we humans 0:09:29.960 --> 0:09:34.679 are generally much warmer than soil, and in the warm, 0:09:35.080 --> 0:09:40.960 wet gooiness that is our body environment, this fungus transforms 0:09:41.120 --> 0:09:46.760 into a budding yeast, yeast being a unicellular type of 0:09:47.080 --> 0:09:49.440 fungus like the kind that you make bread with, except 0:09:49.559 --> 0:09:53.640 it's not at all like your bread yeast, and so 0:09:53.760 --> 0:09:56.120 that's what it means to be dimorphic. It has this 0:09:56.240 --> 0:09:59.760 yeast form that exists inside of us or inside of 0:09:59.760 --> 0:10:03.800 ho ghosts at higher temperatures, and a mold form that 0:10:03.920 --> 0:10:08.920 exists in the environment. Coxidioidomycosis that we covered on this 0:10:08.960 --> 0:10:11.479 podcast is also thermally dimorphic. 0:10:11.800 --> 0:10:13.800 Great pronunciation, thank you. 0:10:13.920 --> 0:10:20.119 I practice, as is histoplasmosis, which I'm sure will cover eventually. 0:10:21.040 --> 0:10:24.240 And it turns out quite a lot of fungi of 0:10:24.320 --> 0:10:31.040 medical importance are thermally dimorphic. And it's not only temperature 0:10:31.400 --> 0:10:35.320 that triggers this dimorphism. It's also things like how much 0:10:35.400 --> 0:10:39.080 carbon dioxide they're exposed to, which of course is much 0:10:39.160 --> 0:10:43.959 higher in our lungs than in our air. So once 0:10:44.080 --> 0:10:48.120 we inhale these spores and they're inside of us, they 0:10:48.280 --> 0:10:51.800 get eaten up by macrophages, which again are one of 0:10:51.840 --> 0:10:54.840 our white blood cells that are good at gobbling things 0:10:54.880 --> 0:10:58.800 that don't belong in us. And then they do this 0:10:58.960 --> 0:11:03.360 transform in to yeast thing and start butting as a 0:11:03.440 --> 0:11:05.839 yeast does in order to make more of itself. That's 0:11:05.880 --> 0:11:10.960 the way that it reproduces. And what's so fascinating is 0:11:11.000 --> 0:11:15.960 that in this process, during this transformation into yeast, what 0:11:16.000 --> 0:11:19.840 this fungus starts to do is up regulate all of 0:11:19.920 --> 0:11:24.000 these genes that, like, why do they have these genes? 0:11:24.600 --> 0:11:30.319 These genes that are specifically good at evading our immune system. 0:11:31.280 --> 0:11:35.920 So these are things like adhesions and calcium binding proteins 0:11:36.080 --> 0:11:40.040 and outer wall glycoproteins, all of these boring names of 0:11:40.080 --> 0:11:45.000 things that basically help this yeast stick to our cells 0:11:45.720 --> 0:11:52.360 and actively evade our immune defenses. Uh huh, it's amazing, 0:11:52.559 --> 0:11:55.959 it's so cool. So all of these genes are doing 0:11:56.000 --> 0:12:01.280 things like inhibiting major cytokines that we use in our 0:12:01.280 --> 0:12:05.240 defense like TNF alpha, we'll come back to it, and 0:12:05.480 --> 0:12:11.440 inhibiting the activation of our t lymphocytes. Like it's it's 0:12:11.480 --> 0:12:16.880 incredible what this yeast, this fungus is able to do. Yeah, 0:12:17.040 --> 0:12:19.360 and when they do this. On top of all of that, 0:12:19.559 --> 0:12:22.880 they also have to rearrange all of their cell walls, 0:12:23.400 --> 0:12:27.480 and in doing this, in this transformation from hyphi to yeast, 0:12:27.600 --> 0:12:31.800 it's yet another way to further confuse our immune system 0:12:32.160 --> 0:12:35.200 and make it harder to block this infection. 0:12:37.559 --> 0:12:43.040 You know, Okay, I love this and I can't like 0:12:43.120 --> 0:12:45.480 This ties in so well with what I'm. 0:12:45.320 --> 0:12:47.960 Going to be talking about. Yeah, I'm excited about it. 0:12:48.000 --> 0:12:49.600 I'm excited. Good, we too. 0:12:49.679 --> 0:12:52.480 We feel like this is going to be much more 0:12:52.520 --> 0:12:54.880 of a mind blowing episode, I hope, or at least 0:12:54.880 --> 0:12:56.839 it was for me, and it is right now in 0:12:57.040 --> 0:12:59.480 hearing you talk about it. Oh, good than I ever 0:12:59.520 --> 0:13:01.640 thought a fungal infection could be. 0:13:01.920 --> 0:13:04.760 I can't now, I'm like even more excited for the 0:13:04.880 --> 0:13:09.640 history section. Wow. But so, that is one of the 0:13:09.640 --> 0:13:17.200 things that makes blastomycosis specifically not considered just an opportunistic infection. 0:13:17.920 --> 0:13:21.280 A lot of fungal infections we think of as mostly 0:13:21.320 --> 0:13:24.400 being a problem for people who have various degrees of 0:13:24.440 --> 0:13:27.960 immunal compromise, and it's definitely true that for people with 0:13:28.040 --> 0:13:32.160 things like deficiencies in their T cell function, for example, 0:13:32.360 --> 0:13:36.600 in advanced HIV or AIDS, or people who are maybe 0:13:36.600 --> 0:13:42.640 on TNF alpha inhibitors, that important cytokine, those people are 0:13:42.720 --> 0:13:47.400 potentially at much higher risk of severe infection. But this 0:13:47.480 --> 0:13:52.640 is a fungus that can infect all of us da dadoo. 0:13:53.760 --> 0:13:58.400 So it's fascinating. It turns out that it's about fifty 0:13:58.440 --> 0:14:01.920 to fifty whether you actually are going to have symptoms 0:14:02.000 --> 0:14:06.040 from exposure to Blastomyces. Okay, and that is a little 0:14:06.080 --> 0:14:08.000 more than I expected for a fungus. 0:14:09.400 --> 0:14:14.679 Yeah, Like, how has that number been calculated with? Like, 0:14:14.840 --> 0:14:18.960 is it just from known outbreaks or known exposures? 0:14:19.320 --> 0:14:23.720 I think so, good question. Okay, Yeah, my guess is yes, 0:14:23.760 --> 0:14:26.080 it's from like various studies where they've tried to actually 0:14:26.080 --> 0:14:28.400 look at you have an outbreak, and then you try 0:14:28.400 --> 0:14:30.880 and look at a larger population. How many people do 0:14:30.920 --> 0:14:33.680 you find infected that never had symptoms? Right? 0:14:33.720 --> 0:14:36.600 Who who might have been at the pond near the 0:14:36.680 --> 0:14:37.720 rotting wood that day? 0:14:37.760 --> 0:14:44.200 Also exactly? And when it comes to symptoms, there are 0:14:44.360 --> 0:14:49.520 two main classes of symptoms. There's pulmonary and there's extra 0:14:49.600 --> 0:14:55.400 pulmonary aka everywhere else in your body. And like many 0:14:55.480 --> 0:15:00.640 fungal infections, this is a slow growing pathogen. Symptoms can 0:15:00.640 --> 0:15:04.480 take anywhere from three weeks to three months or more 0:15:04.600 --> 0:15:06.920 to develop after exposure. 0:15:07.440 --> 0:15:11.800 Okay, So I have a question, uh huh, because from 0:15:12.240 --> 0:15:14.840 and maybe this is just because I was reading older papers, 0:15:14.920 --> 0:15:20.840 but I thought that the environmental sources of Blastomyce's dermatititis 0:15:20.960 --> 0:15:24.920 is not they haven't been super well characterized and it's 0:15:24.960 --> 0:15:27.880 not reliably isolated from the environment. So how you know 0:15:28.520 --> 0:15:32.120 if an exposure was three weeks ago or three months ago. 0:15:32.480 --> 0:15:34.800 That's such a good question, especially if you're living in 0:15:34.840 --> 0:15:38.760 an endemic area. Right, I don't think we know, Okay, 0:15:39.000 --> 0:15:41.160 because also three weeks and three months is a very 0:15:41.200 --> 0:15:44.960 wide range. Yeah, it's very wide. So is the range 0:15:45.000 --> 0:15:47.720 really that wide or do we just not know that? Well? 0:15:47.800 --> 0:15:50.400 Right, it's like, well, I think three months ago, I 0:15:50.440 --> 0:15:54.160 guess I went camping there. But right, that's but maybe 0:15:54.160 --> 0:15:57.320 you forgot about something that was not camping that could 0:15:57.320 --> 0:15:58.200 have been an exposure. 0:15:58.280 --> 0:16:01.120 Okay, And maybe we have slightly better data from people 0:16:01.240 --> 0:16:05.960 who go to an endemic area and become exposed and 0:16:05.960 --> 0:16:08.960 then leave that endemic area and then have symptoms later. Okay, 0:16:09.680 --> 0:16:11.640 But yeah, you're right, a lot of this is a 0:16:11.640 --> 0:16:15.280 little bit messy. As you'll see, we don't have the answers. 0:16:17.080 --> 0:16:19.120 We're so not used to that on this podcast. 0:16:19.440 --> 0:16:25.320 It's never happened before. Oh yeah, So let's get into 0:16:25.480 --> 0:16:29.440 what this disease looks like when people are symptomatic. So 0:16:29.520 --> 0:16:31.400 for those fifty percent of people who are going to 0:16:31.440 --> 0:16:35.640 show some kind of symptoms, over eighty percent will have 0:16:36.000 --> 0:16:40.160 some type of pulmonary infection because again, most of the 0:16:40.200 --> 0:16:44.760 time we're being exposed by inhaling spores or inhaling hyphie. 0:16:45.720 --> 0:16:49.360 But even this pulmonary infection can be very broad in 0:16:49.440 --> 0:16:55.600 terms of symptoms. For some people it's a relatively minor pneumonia, 0:16:55.720 --> 0:16:59.120 for others, it can be as severe as acute respiratory 0:16:59.160 --> 0:17:03.520 distress syndrome that can lead to death. So in the 0:17:03.560 --> 0:17:06.960 case of more mild infections, like just a run of 0:17:06.960 --> 0:17:11.000 the mill pneumonia, we're looking at things like fevers. You 0:17:11.080 --> 0:17:16.000 might have chills, a cough, some difficulty breathing, chest pain. 0:17:16.800 --> 0:17:19.399 These are symptoms that are easy to confuse with any 0:17:19.480 --> 0:17:23.760 other kind of community acquired pneumonia, And when we look 0:17:23.800 --> 0:17:27.280 at an X ray, it's usually pretty indistinguishable from that 0:17:27.359 --> 0:17:30.800 perspective as well from any other bacterial cause there's nothing 0:17:30.920 --> 0:17:36.600 that makes a Blastomyce's pneumonia stand out necessarily, and that 0:17:37.119 --> 0:17:39.840 is one of the first problems, right, because that's going 0:17:39.880 --> 0:17:42.800 to make it a lot harder to diagnose. And so 0:17:42.920 --> 0:17:47.879 because of this, a relatively minor pneumonia can easily progress 0:17:48.119 --> 0:17:53.000 to a chronic pneumonia that just kind of persists because 0:17:53.040 --> 0:17:55.879 it's not going to be treated with whatever antibiotics somebody 0:17:56.000 --> 0:17:59.960 might take, or it can progress to an acute reread 0:18:00.000 --> 0:18:02.440 inspiratory distress syndrome or ards. 0:18:03.280 --> 0:18:05.600 And can it spontaneously resolve. 0:18:06.400 --> 0:18:12.040 It's a good question. I don't know, Okay, yeah, So 0:18:12.440 --> 0:18:14.840 on the chronic end of things, it could certainly be 0:18:15.320 --> 0:18:19.160 very mild symptoms for a long time. This is something 0:18:19.200 --> 0:18:22.600 that can mimic tuberculosis or even lung cancer, and so 0:18:23.119 --> 0:18:26.040 a lot of times those diseases might have very long 0:18:26.160 --> 0:18:30.520 periods where the symptoms are mild enough that people might not, 0:18:31.200 --> 0:18:35.000 you know, seek care in that way, or maybe not 0:18:35.040 --> 0:18:39.720 have access to care. But I didn't read anything about 0:18:39.760 --> 0:18:44.119 like spontaneous resolution necessarily. Okay, if you progress to the 0:18:44.160 --> 0:18:48.280 point where you're having symptoms, right, yeah, okay, yeah, it's 0:18:48.320 --> 0:18:52.040 a good question. But yeah, so in a chronic infection, 0:18:52.400 --> 0:18:56.760 people might have night sweats, they might have some weight loss, 0:18:57.280 --> 0:19:00.800 a persistent cough. They might even progress to coughing up 0:19:00.840 --> 0:19:04.919 blood or hemoptosis. But again, even in this case, the 0:19:05.080 --> 0:19:08.120 X ray findings are not very specific. They can look 0:19:08.320 --> 0:19:13.240 like cancer, they could look like tuberculosis. So unless somebody 0:19:13.320 --> 0:19:17.639 has a very clear risk factor like working construction in 0:19:17.680 --> 0:19:21.439 the Ohio River Valley or something like that, or the 0:19:21.560 --> 0:19:26.320 diagnostic team thinks to check for blastomycosis, which is more 0:19:26.440 --> 0:19:29.080 likely to happen in an endemic area than in a 0:19:29.119 --> 0:19:33.240 place where blastomycosis doesn't exist, it might take months before 0:19:33.240 --> 0:19:37.119 the correct diagnosis is reached in those cases. But the 0:19:37.160 --> 0:19:41.440 scary part is if it progresses to acute respiratory distress syndrome, 0:19:41.960 --> 0:19:44.520 and this is something that can happen even just after 0:19:44.600 --> 0:19:48.159 an acute pneumonia, within a few weeks, and has the 0:19:48.200 --> 0:19:52.080 potential for a greater than fifty percent mortality rate even 0:19:52.119 --> 0:19:56.120 with treatment. I think even with treatment, because it can 0:19:56.160 --> 0:20:01.320 be so rapid if it progresses in this direction, not 0:20:01.400 --> 0:20:03.920 a fifty percent mortality rate for just a chronic infection, 0:20:04.040 --> 0:20:06.720 but if it gets to the point where you basically 0:20:06.760 --> 0:20:09.560 have your lungs filling up with fluid because of how 0:20:09.920 --> 0:20:14.600 much inflammation there is. Then yes, it's a fifty percent 0:20:14.640 --> 0:20:19.240 mortality rate because, as we'll see, treatment for fungal infections 0:20:19.240 --> 0:20:23.880 in general and blastomycosis specifically is really prolonged. It takes 0:20:24.040 --> 0:20:27.640 months and months of antifungal treatment to clear this infection. 0:20:30.200 --> 0:20:35.359 So that's the kind of pulmonary syndrome of blasteromycosis. But 0:20:35.480 --> 0:20:40.920 of course this fungus is among us. I was really 0:20:40.920 --> 0:20:43.320 trying to throw that in there. Some whort is very 0:20:43.359 --> 0:20:47.200 well shoehorn in right there. Thank you, just made it work. 0:20:47.680 --> 0:20:53.359 It's not limited to our lungs because once these blastomyces 0:20:53.520 --> 0:20:57.120 transform into their yeast form, our bodies have a really 0:20:57.200 --> 0:21:00.760 hard time doing anything about them, and so then they 0:21:00.800 --> 0:21:03.920 can just disseminate either through our blood stream or through 0:21:03.920 --> 0:21:09.240 our lymphatics and just cause disease theoretically anywhere, but there's 0:21:09.280 --> 0:21:11.719 a few places that tend to be the most common. 0:21:12.359 --> 0:21:15.439 So the second most common place of infection outside of 0:21:15.480 --> 0:21:20.040 the lungs is the skin. Forty to eighty percent of 0:21:20.080 --> 0:21:23.560 people that have disseminated disease, So any disease outside of 0:21:23.560 --> 0:21:28.399 the lungs have some type of skin manifestation, and these 0:21:28.440 --> 0:21:31.359 can vary a lot in what they look like, but 0:21:31.440 --> 0:21:36.680 they're often fairly gnarly. They can look like these like nodules. 0:21:36.880 --> 0:21:41.480 Sometimes it's like a purplish nodule, or like a plaque, 0:21:41.480 --> 0:21:45.480 which is like a large, several centimeter wide kind of 0:21:45.560 --> 0:21:50.080 circle raised on your skin that can progress to like 0:21:50.160 --> 0:21:55.280 an ulcer or even an abscess, and they can continue 0:21:55.320 --> 0:21:59.480 to progress to these very large, necrotic or completely dead 0:21:59.520 --> 0:22:03.400 tissue usions that can lead to permanent scarring if they're 0:22:03.440 --> 0:22:08.240 not treated nice. Yeah. And after skin, the second most 0:22:08.320 --> 0:22:13.520 common sight of dissemination is our bones. And this can 0:22:13.560 --> 0:22:16.720 happen either directly from a skin infection that then just 0:22:16.800 --> 0:22:21.080 kind of makes its way into the bone, or it 0:22:21.119 --> 0:22:23.680 can just go from your lungs straight to the bone 0:22:23.720 --> 0:22:24.640 through your bloodstream. 0:22:25.160 --> 0:22:27.840 How does something go into our bones? 0:22:28.000 --> 0:22:30.560 Oh? I mean lots of infections can go into your bones. 0:22:30.600 --> 0:22:32.400 Your bones are a living things. 0:22:32.520 --> 0:22:36.560 I remember, was it tuberculosis episode? I can't remember, but 0:22:36.760 --> 0:22:40.440 that sounds right. Why? How? 0:22:40.920 --> 0:22:44.840 Yeah? Well why I think why is a more interesting 0:22:44.920 --> 0:22:47.280 question than how, because how it's just like, oh, it's 0:22:47.320 --> 0:22:52.160 our bloodstream, but why, like why is it so good 0:22:52.200 --> 0:22:55.520 at getting into our bones when other infections aren't exactly 0:22:55.800 --> 0:23:02.480 I don't know. It's a good question, though, Wow, but 0:23:02.640 --> 0:23:07.040 this is not uncommon. About five to twenty five percent 0:23:07.200 --> 0:23:13.000 of cases of disseminated blastomycosis can cause an osteomyelitis. And 0:23:13.040 --> 0:23:16.080 then this, once it's in the bone, can then extend 0:23:16.200 --> 0:23:20.000 into our joints or into the soft tissues like muscles 0:23:20.000 --> 0:23:23.920 and ligaments and result in a septic arthritis or deep 0:23:24.080 --> 0:23:25.120 deep abscesses. 0:23:26.160 --> 0:23:33.440 So the lesions are an indication of disseminated disease regardless 0:23:33.480 --> 0:23:36.760 of whether it's just one lesion or lesions all over 0:23:36.800 --> 0:23:37.280 your body. 0:23:37.760 --> 0:23:41.679 Excellent question. Most of the time. Yes, it is possible 0:23:42.040 --> 0:23:45.800 to have just a skin infection if you got exposed 0:23:46.040 --> 0:23:50.280 via inoculation in the skin, that is possible, but it's 0:23:50.359 --> 0:23:56.040 much less common because pulmonary infection is so much more common. Overall, 0:23:56.119 --> 0:23:59.239 it's more likely that there was a pulmonary infection that 0:23:59.320 --> 0:24:01.280 made it through the bloodstream and then made it to 0:24:01.320 --> 0:24:07.200 the skin, even if there's only one skin lesion. Okay, yeah, yeah, 0:24:07.640 --> 0:24:11.880 it's a good question. Beyond our skin and our bones, 0:24:12.000 --> 0:24:15.040 the two other places that are most common, And again, 0:24:15.600 --> 0:24:19.480 why such a good question, I don't know. But the 0:24:19.520 --> 0:24:23.240 two other places that are most common to see blastomycosis. 0:24:23.280 --> 0:24:28.119 Infections are the genito urinary tract, and this means any part. 0:24:28.359 --> 0:24:32.240 It can be an epididymitis, it can be a prostatitis, 0:24:32.720 --> 0:24:37.439 it can be an endometritis, it can be cystitis, which 0:24:37.560 --> 0:24:41.080 is your bladder. So this is just literally any organ 0:24:41.240 --> 0:24:47.399 involved in the genitourinary system. And then there is the 0:24:47.440 --> 0:24:52.120 central nervous system infection, so that's brain and spinal cord. 0:24:52.800 --> 0:24:57.359 And this can happen either from bloodborne spread crossing over 0:24:57.440 --> 0:25:02.280 that blood brain barrier, or from an osteomylitis so a 0:25:02.320 --> 0:25:06.680 bone infection in the skull that then progresses. Sorry, your 0:25:06.680 --> 0:25:11.720 face does not like that muntal image, I know. And 0:25:11.800 --> 0:25:14.840 as with many infections that we've talked about that can 0:25:15.119 --> 0:25:18.840 infect our brain or our spinal cord, the symptoms here 0:25:19.000 --> 0:25:22.440 can really range. They can be a headache, they can 0:25:22.480 --> 0:25:27.640 be confusion, they could be any range of neurologic deficits 0:25:27.920 --> 0:25:32.600 like seizures or visual disturbances. It's a really really wide 0:25:32.720 --> 0:25:35.480 range of potential nervous system symptoms. 0:25:36.160 --> 0:25:42.360 These different roots that a disseminated infection can take may 0:25:42.440 --> 0:25:47.160 or may not be affected by anti fungals, like whether 0:25:47.320 --> 0:25:51.280 or not it progresses to central nervous system involvement. Can 0:25:51.320 --> 0:25:53.320 you stop that? Or is it like, oh, we didn't 0:25:53.320 --> 0:25:56.600 know what this infection was. Suddenly now there's central nervous 0:25:56.600 --> 0:26:00.800 system involvement. Someone goes to the doctor and they're like, well. 0:26:01.800 --> 0:26:04.120 Yeah, that's a good question. I don't have like an 0:26:04.160 --> 0:26:08.159 exact answer for you. I can say that overall, the 0:26:08.280 --> 0:26:12.879 case fatality rate based on studies in hyperendemic regions is 0:26:12.920 --> 0:26:17.040 about four to six percent, and most of those likely 0:26:17.119 --> 0:26:22.280 had pretty severe infection, either widely disseminated in multiple organs 0:26:22.440 --> 0:26:26.080 or a central nervous system infection, or just a very 0:26:26.160 --> 0:26:31.040 bad ards or acute respiratory distress syndrome. It's not that 0:26:31.280 --> 0:26:36.240 it's impossible to treat if it's a disseminated infection. It's 0:26:36.320 --> 0:26:41.280 just that this is a difficult pathogen to treat regardless 0:26:41.320 --> 0:26:44.520 of where the infection is. So if it's already disseminated, 0:26:44.520 --> 0:26:48.639 you're likely dealing with a much larger fungal load that 0:26:48.680 --> 0:26:52.960 you have to deal with, right and the drugs that 0:26:53.000 --> 0:26:58.120 we use to treat fungal infections, namely amphotericin B. If 0:26:58.119 --> 0:27:02.280 it's a especially if it's a severe infection or various 0:27:02.320 --> 0:27:07.840 forms of connaisols like intriconoisol. These are not drugs without 0:27:07.880 --> 0:27:10.280 their own sets of risks. They can be pretty hard 0:27:10.320 --> 0:27:12.800 on the liver, pretty hard on the kidneys, have a 0:27:12.840 --> 0:27:16.960 lot of drug drug interactions. So, yeah, this is a 0:27:17.040 --> 0:27:20.120 disease that's difficult to diagnose and then difficult to treat, 0:27:20.240 --> 0:27:27.520 especially depending on how severe it's gotten to begin with. Yeah. Yeah, 0:27:27.640 --> 0:27:31.439 And while this is a disease that can infect and 0:27:31.600 --> 0:27:35.720 does infect immunal competent people, people with a fully functional 0:27:35.720 --> 0:27:40.400 immune system, in people with various degrees of immunal compromise, 0:27:40.720 --> 0:27:44.600 the risk of severe infection and the mortality rate can 0:27:44.640 --> 0:27:48.679 be significantly higher, in some cases, as high as forty 0:27:48.720 --> 0:27:53.320 percent in people with poorly controlled HIV or AIDS, or 0:27:53.440 --> 0:27:56.040 people with a history of a solid organ transplant who 0:27:56.040 --> 0:28:03.000