What is Blastomycosis?

((All of this information can be found at http://blastomycosis.ca/forum/index.php/topic,559.0.html))

Blastomycosis (Blasto) in the dog is a commonly misdiagnosed systemic fungal disease of dogs, humans and other mammals. It is a great pretender and opportunist that can be mistaken for cancer, viral infections, Lyme Disease, or other systemic fungal diseases such as Valley Fever. Many dogs die or are euthanized each year due to delay in treatment as the result of a missed or erroneous diagnosis. Involvement of the eye may cause loss of vision or necessitate the removal of the eye.  Relapse is also a concern, more often reported in females.  

   Canine Blastomycosis is caused by Blastomyces dermatitidis. This parasitic fungus grows as a mold in moist soil or decaying vegetation and releases spores into the environment that can be inhaled by animals or humans. Young dogs that have access to the outdoors are prime candidates for blastomycosis infection, but infection has been documented in all canine breeds, cats, horses and ferrets. 

   Normally, blastomycosis infection will begin in the lungs after spores are inhaled and transform into large thick-walled budding yeast, which can multiply and disseminate to other areas of the body.  Dissemination into organs, lymph nodes, eyes, testicles, joints, skin, as well as the central nervous system, is a grave risk.

   A diagnosis of Canine Blastomycosis must be made promptly in order to begin treatment with antifungal medications. Unless Blasto is suspected, valuable time is often wasted testing and treating for viral and bacterial infections while the fungus disseminates. Without quick recognition, accurate diagnosis, and access to reasonably priced medications, many animals are unnecessarily lost to Blasto. A high index of suspicion is crucial.

   Blastomycosis cannot be eradicated from the environment, however, one may attempt to avoid or remove possible sources of contamination, such as mulched areas of flower beds, paths, bedding, areas of wetlands, etc.  The idea of a commercial fungicide has been discussed, but there are none currently available that are effective against Blasto.

  With the advent of compounding pharmacies and generic antifungal medications, treatment is now more effective and affordable, making successful outcome for these animals more attainable than ever. Sadly enough, as the symptoms can be widely varied and non-specific, there is sometimes a reluctance to diagnose what has previously been considered a “rare” condition. 

Risk Factors:

 Endemic Areas, US - Mississippi, Missouri, Ohio River valleys, Eastern Seaboard, areas adjacent to the Great Lakes.  States with highest endemnicity are Wisconsin, Minnesota, Missouri, Illinois, Michigan, Kentucky, West Virginia, Arkansas, Tennessee, North Carolina, South Carolina, Louisiana, and Mississippi. Other endemic states include Indiana, Iowa, Ohio, Virginia, Georgia, and Alabama. However, cases do occur outside the endemic areas.  

 Endemic Areas, Canada - Blasto is prevalent in Kenora, Ontario. Also found in Manitoba, Ontario (Kenora, Sault Ste. Marie, Chapleau), Quebec, New Brunswick, in particular areas around the Great Lakes and in a small area a small area in New York and Canada along the St. Lawrence River. Has also been increasingly reported along the Georgian Bay coastline (including Midland and Penetang), Dryden, and in Southern Ontario at the Rockwood Conservation area.

 Environment  - Research shows that exposure to wet or decaying organic material, recently disturbed soil, rotting vegetation, bird droppings, and landscaping projects is a strong indicator of disease possibility. Some research has shown a strong link to wood mulch and importation of non-local soil.  Patient history will often reveal exposure to mulched areas and disturbed soil in parks, yards, walking paths, etc. By questioning an owner about the animals’ activities, it is often found that exposure may have occurred while vacationing, camping, or visiting an area where Blastomycosis is endemic.

 Breed/Age – Young, large-breed dogs  with the highest rates of infection are normally Coonhounds, 
Pointers, and Weimaraners.  This is normally attributed to higher exposure to endemic areas due to use in hunting.  Breed, size, and age, however, are not a reliable indicator of susceptibility, as all are at risk

 Symptoms:

   After initial spore inhalation, incubation can range from days to weeks, sometimes months, which makes pinpointing a source of infection extremely difficult.  The presentation of Blasto is often non-specific, and can imitate a range of other diseases.  Symptoms include:

 Lethargy
 Persistent fever of 103 degrees or more
 Anorexia
 Vomiting
 Persistent, usually non-productive cough
 Exercise intolerance
 Respiratory symptoms, fungal pneumonia
 Ocular infection, sudden blindness
 Depression
 CNS symptoms: twitches, stumbling gait, loss of coordination
 Skin ulcerations, non-healing lesions
 Lumps, nodes, swellings
 Weight loss
 Hair loss
 Lameness, fungal arthritis
 Hematuria 

Diagnostic Testing:
   
   Diagnosis is based on clinical signs, a thorough patient history, and laboratory findings.  Not all findings are specific, some tests are faster and more efficient, and some cases may benefit from antifungal treatment even before definitive diagnosis. 

 Cytology: New Methylene Blue stain used to identify organisms from exudates of skin abcesses/lesions/sputum/fluid aspirated from lungs appears to be the fastest, most reliable and cost-effective method.  Not all cases, however, will present with accessible material, necessitating further diagnostics.
 MiraVista Diagnostics Antigen Assay: Very high sensitivity with urine (studies show 92.9% sensitivity, specificity 79.3%), slightly less sensitive with serum. 4-5 days for results, at a cost of approx. $100.  Also useful in monitoring the efficacy of antifungal therapy.
 Chest X-Ray –  signature “snowstorm” pattern 
 Area Bone Radiograph 
 Lymph node biopsy / fine needle aspiration 
 Serum Antibody Titer: regarded as a fairly poor diagnostic tool for Blastomycosis
 Tracheal wash
 Ultrasound

Be Aggressive: 

   Excerpt: Journal of Clinical Microbiology, October 2004, p. 4873-4875, Vol. 42, No. 10
   “Most patients with blastomycosis exhibit progressive illnesses that require antifungal therapy. In one study, diagnosis was delayed for more than 1 month in nearly half of the cases. Blastomycosis was correctly suspected in only 20% of patients, resulting in unnecessary surgeries and treatment delays. In two-thirds of patients who died of acute respiratory distress syndrome caused by blastomycosis, the diagnosis was either not suspected or considered only after the patient became moribund.”

Treatment Options*:

 Itraconazole (Sporanox) capsules: First line preferred treatment, given with a fatty food to increase bioavailability
 Amphoterericin-B: Higher efficacy in patients with CNS involvement
 Itraconazole (Sporanox) suspension: Shorter shelf-life, but can be given without food
 Ketoconazole (Nizoral): In initial treatment w/Ampho-B, similar results as Itraconazole - slightly less expensive
 Fluconazole (Diflucan): Somewhat generally less effective than Itraconazole, but may have better effect in cases with CNS and/or eye involvement.
 Posaconazole: Higher cost, similar effects to Itraconazole, few studies
 Voriconazole: Higher cost, somewhat better efficacy in cases w/CNS involvement, few studies
 Prednisone: For treatment of inflammatory issues
*http://www.miravistalabs.com/Files/pdf/BlastomycosisinDogs2007.pdf.

    In the past, Amphotericin-B was the only known medication useful against Blastomycosis and the other systemic fungal organisms.  It was given intravenously and with care to keep the dose from harming the kidneys.  

   More recently, research has provided oral azoles that are highly effective in treating fungal infections.  Itraconazole (Sporanox), Ketoconazole (Nizoral), and Fluconazole (Diflucan) are available as capsules and oral suspensions that may be administered for 3 to 6 months (depending on the severity of infection, treatment may be even longer). 

   Compounding pharmacies have made these medications much more affordable and available in custom dosages for different sized animals.  Generic and brand name medications are equally effective, and given the very high cost of brand names, the generic compounded alternatives are saving lives that may have previously been lost due to the cost and length of treatment.

Treatment – It Gets Worse Before it Gets Better:

   Once Blasto is diagnosed or is highly suspected, treatment can be started with the appropriate antifungal medication.  In the early stages of treatment large numbers of fungi begin to die in the lungs and often elicit an inflammatory response. Prednisone is sometimes prescribed to help reduce inflammation issues.

   Many of these animals are fighting a fungal pneumonia.  As a result, respiratory distress is often a significant problem in the first few days following initiation of therapy. Since the severity of the infection will determine the amount of fungi inhabiting the dog’s lungs, early diagnosis and treatment is an efficient means of reducing post-treatment respiratory distress and can significantly influence a dog’s chances of survival.  

  The animal’s prognosis will always be guarded, and antifungal treatment is never a guarantee of recovery. Intense supportive care and a high level of commitment to recovery on the part of the owner are imperative. Round the clock care is often necessary.  Removal to a medical facility for IV treatment and hydration may be helpful and sometimes unavoidable, but can be very stressful for a compromised animal. If the owners are able to provide care, the security of home and loved ones may reduce stress.  The outcome will also vary with the degree of infection, whether Blasto has disseminated into other organs, CNS, bones, or in the event of secondary bacterial or viral infection.  

   Eye involvement may result in blindness or necessitate removal of eye(s).  Recently some experimental treatments have reported some success in the nominal recovery of vision. These treatments can be fairly expensive, and are not a guarantee of sight recovery. (**See Dogs In Canada article: “Blasto What”, by Rick Hayward.)

   During the first few weeks of therapy, the animal may become alarmingly ill, anorexic, and may have to be force-fed.  Weight loss may continue; hydration and calories are important.  During this time, the idea of eating “healthy” may need to be suspended in favor of getting any nutrition possible into the animal. Owners who have successfully treated their animals recommend the following:

 Ensure Plus: added protein with about 300 calories per can; well tolerated, may be bottle-fed
 Hill’s A/D canine "prescription" dog food: can be mixed with water and given by syringe
 Canned Tripe
 Sav-A-Calf Electrolytes Plus: very good reported results, may be bottle-fed
 Canned Dog Food
 Cooked chicken, chicken broth
 Meal Bones-Whole meals
 Stewed meats, soups
 Burger
 Peanut butter: lots of fat and calories, and they pretty much cannot avoid swallowing it
 Frozen Gatorade
 Frozen Ensure
 Frozen Pedialyte: also helpful when used in a squirt or spray bottle
 Cheese
 Ice Cream
 Margarine
 Sausage
 Eggs
 Yogurt


   Medication: Sources and Cost:

   Antifungal prescriptions from retail pharmacies can range from $4 to $9 per dose.  As treatment must be continued for as long as 12 months, cost will be an issue that affects the owners’ decision regarding treatment vs. euthanasia. 

   Compounding pharmacies have made generic and custom doses much more affordable.  For example, the cost of generic Itraconazole 150 mg. from Pet Health Pharmacy in Arizona is approximately $1 per dose.  Overnight shipping is available at a cost of about $8-$10 extra. These medications appear to be equally effective as brand name varieties and make the option of treatment more feasible for the owner.  

   Contact information for a few trusted compounding pharmacies, more available at www.veterinarypartner.com/Content.plx?A=546

 Pet Health Pharmacy, Inc.: Highly recommended. 12012 N 111th Ave. Youngtown, AZ 85363
Toll Free Phone (800) 742-0516 · Toll Free Fax (866) 373-0030
 RoadRunner Pharmacy:   711 E. Carefree Highway, Suite 140  Phoenix, AZ  85085
Toll Free Phone (877) 518-4589
 Victoria Compounding Pharmacy: 1089 Fort St.  Victoria, BC  V8V 3K5, Canada
Telephone: (250) 388-5181
 American Health Solutions Pharmacy, Inc.: (800) 337-2844
 Wedgewood Pharmacy: (800) 331-8272, (888)-678-1967 Veterinary 

To Sum It Up:

   The information in this newsletter was compiled over the course of approximately one year, and is a collaborative effort undertaken by a group of people who have first-hand experience with Blastomycosis in their animals and/or loved ones during the last year.  
   On the web, it began at www.Blastomycosis.ca, a website by Lisa Schuyler, dedicated to her beloved Golden Retriever, Surf, who died of Blasto in 2005.   The site has become a wealth of information, research, links, tips, and support from people who have had successful outcomes and/or suffered the loss of their animals or loved ones.

   As discussed, Blasto is often misdiagnosed, or valuable time ticks away while treating for ailments that may be considered more common.  By reading the case database at Blastomycosis.ca, it quickly becomes apparent that the key to a successful outcome is not the amount of money spent on expensive care, name brand medications or tests.  

   The reality is often quite the opposite: some severe cases were successfully treated at home for less than $1000, while others spent well into the thousands on hospital care and brand name treatments, only to lose their animals. The difference is in timely diagnostics, access to affordable medications, and the dedication to weeks or months of intensive care for a very sick animal.

    Blasto is no longer rare, but increasingly prevalent in endemic areas as well as areas that are not considered a risk, such as Texas and Vermont.  It is our hope that by circulating this resource, we can raise awareness and save the life of even one animal.  
   
    Visit Blastomycosis.ca and read the wonderful success stories of dogs like Wilson, Will, Gunner, Dirtbike, Marge, and Rocket, as well as the heart-breaking instances of dogs like Missy, Bandit, Roxy, or Chewbakka, who were tragically lost.  The website is frequented by experienced owners who sometimes check in several times a day to offer their support and knowledge to frightened newcomers to Blasto.  Their love and dedication extends to everyone’s animal as if it were their own.  Our thanks to everyone for their time and interest.

On the Web - Resources:
   
   There is a wealth of information available online.  Informed vets and owners make for a better outcome.

 Blastomycosis.Ca: http://blastomycosis.ca/forum/index.php/board,1.0.html
 News Article: Commercial Mulch as a Potential Source of Blastomyces Dermatitides
http://www.acponline.org/about_acp/chapters/de/kambhamettu.htm
 CanisMajor.com: www.canismajor.com/dog/blstomyc.html
 Blastomycosis in the Dog: www.thepetcenter.com/gen/blasto.html 
 ** “Blasto What” by Rick Hayward: www.dogsincanada.com
 Health Articles: www.dogstuff.info/blastomycosis.html 
 Facebook: www.facebook.com/group.php?gid=13680105258&ref=mf

Authors grant permission to reprint, distribute, submit or copy for non-profit purposes only.
Please do not gank or pull the content for your book, and if you choose to reprint it online, link to this site out of respect to the animals we love.

Jennifer S. Wilcox, text
Lee Petterson, pdf. file & pictures
April, 2008