As discussed previously, infection with Blastomyces dermatitidis is primarily associated with outdoor activities including occupational exposure such as construction work, mining, and recreational activities. The AIDS epidemic has not affected the epidemiology of blastomycosis.  Initial infection with this fungus is essentially a pulmonary disease. The chest radiograph demonstrates nonspecific infiltrates predominantly at the bases.  Dissemination to the CNS presents as single or multiple intracranial abscesses or granulomas, cranial and spinal extradural abscesses and acute or chronic meningitis. Meningitis due to B. dermatitidis presents as a subacute infection with headache, anorexia, and weight loss. B. dermatitidis brain abscess or abscesses present with focal neurological deficits, seizures, and signs of increased ICP. Neuroimaging demonstrates evidence of a single or multiple homogeneously enhancing lesions. Chronic blastomycotic meningitis predominantly involves the basilar meninges and may be associated with hydrocephalus.  The one exception to the rule that fungal meningitis presents with a lymphocytic pleocytosis is B. dermatitidis meningitis, which may present with a polymorphonuclear leukocytic pleocytosis. A CSF cell count of greater than 5000 cells/mm 3 is not uncommon. The CSF glucose concentration may be markedly decreased, and the protein concentration is typically elevated. It is rare to identify B. dermatitidis from CSF obtained by lumbar puncture. Culture of cisternal or ventricular CSF has a better yield. There is no reliable B. dermatitidis antigen detection test available.  Treatment requires the administration of intravenous amphotericin B (0.5 to 0.8 mg/kg/d). Lifelong suppressive therapy with itraconazole in AIDS patients is recommended.
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