Most cases of blastomycosis are sporadic and only nine outbreaks representing a total of 112 cases have previously been reported. Less than half of these have been culture proven cases. Outbreaks have previously occurred in North Carolina, Minnesota, Illinois, Wisconsin and Virginia. We report three culturally confirmed cases of blastomycosis from Elizabethton, Tennessee, who had onset of illness within a one-week span of time. The patients presented with fever, chest pain, weight loss, poor appetite and myalgia. Each initially had a dry cough which became productive of purulent sputum as the illness progressed. Mild hemoptysis occurred during each patient's course. Serologic testing by immunodiffusion and enzyme immunoassay were positive and testing by complement fixation was negative in each case. The diagnosis was made by histopathology on transbronchial biopsy or transthoracic needle aspiration material. Each patient improved on ketoconazole therapy.

Study objectives: To study the epidemiologic and clinical features of blastomycosis in northeast Tennessee. Design: Retrospective review of blastomycosis cases in the region from 1980 through 1995. Setting: Hospitals located in the Tri-Cities region of northeast Tennessee. Patients: Seventy- two patients with confirmed blastomycosis infection. Interventions: None. Results: During the 1980 to 1995 study period, we documented 72 cases of blastomycosis. The mean age was 52 years (range, 13 to 86 years), most were male (69.4%), and nine were immunocompromised. A possible environmental exposure was noted for 28 patients. Pulmonary involvement represented the most common site of infection (61 cases), but multiorgan involvement was common (17 cases). Most patients with pulmonary blastomycosis (66%) presented with a chronic illness, and radiologic findings usually revealed local consolidation or a mass-like lesion. Nine patients developed ARDS with an associated mortality rate of 89%, compared with a 10% mortality for non-ARDS pulmonary cases. Antifungal treatment regimens varied widely, with amphotericin B often used for sicker patients. An epidemiologic evaluation revealed that the mean yearly incidence rate for blastomycosis quadrupled between 1980 and 1987 (0.31 cases/100,000 population) and 1988 to 1995 (1.23 cases/100,000 population) (p=0.00001). Most new blastomycosis cases in the 1988 to 1995 period occurred in three counties in the region where significant new construction projects have been underway. Conclusion: Blastomycosis is endemic in northeast Tennessee and the number of eases is increasing, coinciding with major new construction in the region. Clinicians in the area must be alert to this condition.

The epidemiology of blastomycosis remains poorly understood in part due to the lack of a robust and discriminatory strain typing method for Blastomyces dermatitidis. Here we describe the development of a multilocus sequence (MLST) method to study the genetic variation and population structure of B. dermatitidis. Eighty geographically diverse clinical and environmental isolates were examined. Thirty-six unique sequence types were identified. With a discriminatory index of 91.4%, MLST identifies significant genetic diversity for the characterization of local and global B. dermatitidis isolates. To test whether this fungus represented a single species throughout its geographic range we performed phylogenetic analyses, applying Genealogical Concordance Phylogenetic Species Recognition (GCPSR). Phylogenetic analysis revealed two distinct clades, with five of the eight gene phylogenies studied supporting the separation of these lineages, which were also geographically partitioned. Based on fulfillment of GCPSR, we propose the current species B. dermatitidis harbors two genetically distinct non-interbreeding phylogenetic species.

The epidemiology of blastomycosis remains poorly understood in part due to the lack of a robust and discriminatory strain typing method for Blastomyces dermatitidis. Here we describe the development of a multilocus sequence (MLST) method to study the genetic variation and population structure of B. dermatitidis. Eighty geographically diverse clinical and environmental isolates were examined. Thirty-six unique sequence types were identified. With a discriminatory index of 91.4%, MLST identifies significant genetic diversity for the characterization of local and global B. dermatitidis isolates. To test whether this fungus represented a single species throughout its geographic range we performed phylogenetic analyses, applying Genealogical Concordance Phylogenetic Species Recognition (GCPSR). Phylogenetic analysis revealed two distinct clades, with five of the eight gene phylogenies studied supporting the separation of these lineages, which were also geographically partitioned. Based on fulfillment of GCPSR, we propose the current species B. dermatitidis harbors two genetically distinct non-interbreeding phylogenetic species.