THE PATIENT: Ted* a public sector worker in his late 40s
THE SYMPTOMS: Low-grade fever, persistent cough and fatigue
THE DOCTOR: Dr. Neil Shear, head of dermatology at Sunnybrook Health Sciences Centre in Toronto, Canada
FOR THREE WEEKS last February, Ted struggled to banish what he thought was a nasty flu bug. He had a dry cough, a fever of 38 C and a feeling of fatigue that eight hours of sleep— and over-the-counter cold medications—couldn’t fix.
Finally, fed up with feeling lousy, Ted went to his family doctor, who discovered puzzling sores the size of small warts inside his mouth and nose and referred him to the internal medicine clinic at Sunnybrook Hospital in Toronto. The physician there suspected vasculitis, inflammation in the veins and arteries that often presents with fatigue, coughing and skin sores.
It was now April, three months after Ted started feeling sick, and his health quickly deteriorated: his cough worsened and he was so tired he could barely make it through his workday. He’d also lost his typically healthy appetite and was dropping weight. More troubling: the lesions in his mouth and nose were getting larger, and had spread to his throat.
Ted was referred to an oral surgeon, who biopsied the lesions in his mouth. The results were read as granulomatous vasculitis, aligning with the internist’s earlier suspicions. This variant typically involves the upper respiratory tract—an X-ray revealed a fuzzy shadow in Ted’s lungs. The
disease affects about one in 25,000 people, often in their 40s and 50s, and may lead to heart disease and kidney damage. While the condition can be very serious, when it’s diagnosed and treated promptly, the current survival rate is about 90 percent.
Unfortunately, two weeks of taking corticosteroids to control inflammation and suppress his immune system didn’t relieve Ted’s symptoms. The lesions had spread to the skin on his arms, legs and torso, and the abscesses in his mouth and throat made it difficult to eat or talk. By this point, it had been almost six months since the onset of his illness, and Ted had lost hope of ever getting better. Because the sores on his body were so disfiguring, he was referred to dermatologist Dr. Neil Shear.
Shear took one look at the patient and knew he didn’t have vasculitis. “Once you see a condition like this, you don’t forget it,” he says. What Shear saw was blastomycosis, an airborne fungal infection that originates from mould that grows in damp soil and decomposing leaves. It’s found in the U.S. and Canada, as well as parts of India and Africa, and affects people (and animals) who breathe in the spores, though not everyone who’s exposed will develop the infection.
Flu-like symptoms typically appear one to three months after a person inhales the fungus. Once the microorganisms enter the lungs, they transform into a yeast that spreads through the bloodstream. “Eventually, the patient would have been on a ventilator and likely would have died,” Shear says.
Blastomycosis is uncommon in many regions, and Ted is still unsure where he picked up the illness. According to the Centers for Disease Control and Prevention, yearly incidence rates in the U.S. are approximately one to two cases for every 100,000 people. Shear says the infection is often misdiagnosed because it so closely resembles the flu. When reviewing biopsy results, it’s helpful to know what to look for, he says.
In Ted’s case, the fungal elements were noted but weren’t perceived as being significant. “It can take a little extra detective work.”
Fortunately, the condition is treatable. Although Shear performed a second biopsy and fungal culture, he didn’t wait for the results to start a regimen. He promptly prescribed a high dose of antifungal medication two times a day for a month. “After a week, the patient started getting better,” Shear says. Today, Ted has fully recovered.
“Once you see a condition like this, you don’t forget it,” says Dr. Neil Shear.