CTICasesDisseminated Blastomycosis with Miliary Pattern
Imaging findings
Sequential CT scans demonstrate an initial left lower lobe cavitary lesion with necrotic content. Follow-up chest radiograph and CT performed after clinical deterioration reveal a markedly increased profusion of tiny bilateral pulmonary nodules in a miliary pattern, while the dominant cavity has paradoxically decreased in size, consistent with disseminated hematogenous blastomycosis.
Key takeaways
Blastomycosis should be included in the differential for miliary pulmonary disease, especially when a prior CT demonstrates a cavitary pulmonary lesion. The transition from localized cavitary disease to a miliary pattern reflects hematogenous dissemination, which can occur even in immunocompetent hosts, particularly with delayed diagnosis. The presence of a prior cavity narrows the fungal differential toward blastomycosis over histoplasmosis in endemic areas.
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