A 36-year-old woman presented with a several-month history of worsening left upper
quadrant pain and weight loss. A CT scan showed a pancreatic mass and splenic lesions,
and possible splenic vein thrombosis ([Fig. 1]). The patient had no history of immunosuppression, diabetes, or HIV. Her physical
exam was unremarkable except for left upper quadrant tenderness. Her laboratory tests
showed mild microcytic anemia, slight elevation in transaminases, and a two-fold increase
in alkaline phosphatase above normal. Endoscopic ultrasonography (EUS) using Pentax
EG 3630 UR and EG 3630 U echoendoscopes revealed a cystic lesion in the pancreas and
a hypoechoic lesion in the spleen. Aspiration of the pancreas with a 22-G needle and
the spleen with a 25-G needle ([Fig. 2], [3]) revealed necrotic debris and uniform yeast organisms with broad-based budding suggestive
of blastomycosis at both sites ([Fig. 4], [5]). The presumptive morphological diagnosis was confirmed by culture with DNA probe
identification of Blastomyces dermatitidis.
Fig. 1 Abdominal CT scan. The pancreas and spleen are identified. The lesions of interest
are shown by black arrows.
Fig. 2 EUS image of pancreatic lesions during fine-needle aspiration (FNA).
Fig. 3 EUS image of splenic lesions during FNA.
Fig. 4 Initial pancreatic cytology (Diff-Quick preparation). Multiple yeast-like forms are
seen in a background of necrosis.
Fig. 5 Confirmatory Gomori methenamine silver (GMS) staining of the splenic aspiration.
Blastomycosis is an infectious disease caused by the dimorphic fungus Blastomyces dermatitidis [1]
[2]. This disease is endemic to the eastern and central regions of North America along
the Mississippi, Ohio, and St. Lawrence river valleys. Usually it is a self-limiting
pulmonary infection, but systemic spread can occur. Immune suppression does not appear
to increase the risk of acquiring disease, but may alter the manifestations [2]
[3]
[4]. For unknown reasons, the disease disseminates in some patients [2]
[3]
[4]
[5].
We are unaware of any prior reports of EUS being used to diagnose abdominal involvement
in blastomycosis. The use of EUS fine-needle aspiration for diagnosis was ideal in
this particular setting since suggestive material was found from both the pancreas
and spleen at the time of the procedure, and the diagnosis was confirmed by culture
and DNA methodology.
Endoscopy_UCTN_Code_CCL_1AF_2AZ_3AC
