CTICasesDisseminated Blastomycosis with a Miliary Pattern
Imaging findings
The presenting radiograph shows a subtle abnormality in the left lower lobe, poorly seen on the lateral. A repeat radiograph roughly eleven days later is substantially worse, with a new miliary pattern of tiny nodular opacities throughout the lungs and a mass-like consolidation resembling lung cancer that contains the same dry microcavitation without pleural reaction. There is pericardial fluid of uncertain relevance and a mildly generous hilar node, but no bulky adenopathy.
Key takeaways
Blastomycosis can disseminate and produce a miliary pattern even in patients who are not immunosuppressed, and it can do so rapidly, here over roughly eleven days. Comparison with the earlier radiograph was helpful in recognizing the change, and the left lower lobe abnormality was the presumed original site of infection. Treatment is typically itraconazole, sometimes for as long as a year. The principal concern is central nervous system involvement, which can produce brain abscesses or leptomeningitis, though other organs including the skin may be affected.
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