Blastomycosis in man after kinkajou bite.

Abstract

We report transmission of Blastomyces dermatitidis fungal infection from a pet kinkajou to a man. When treating a patient with a recalcitrant infection and a history of an animal bite, early and complete animal necropsy and consideration of nonbacterial etiologies are needed.

Full text

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Blastomycosis
in Man after
Kinkajou Bite
Julie R. Harris, David D. Blaney, Mark D. Lindsley,
Sherif R. Zaki, Christopher D. Paddock,
Clifton P. Drew, April J. Johnson,
Douglas Landau, Joel Vanderbush,
and Robert Baker
We report transmission of Blastomyces dermatitidis
fungal infection from a pet kinkajou to a man. When treat-
ing a patient with a recalcitrant infection and a history of an
animal bite, early and complete animal necropsy and con-
sideration of nonbacterial etiologies are needed.
B
gus causes pneumonia; disseminated infection; or rarely,
cutaneous disease through contact with a wound (1). It is
endemic to southern, south-central, and midwestern states
in the United States, particularly in areas bordering the
Mississippi and Ohio Rivers (2). Outbreaks among humans
have been linked to recreational activities near rivers or
streams in disease-endemic areas (3,4).
Blastomycosis can also affect other mammals (5).
Zoonotic transmission of blastomycosis is rare but has been
reported in association with dog bites (6,7), cat scratches
(8), and animal necropsies (9). We report zoonotic trans-
mission of blastomycosis by a bite from a pet kinkajou.
lastomycosis is caused by inhalation of conidia of the
dimorphic fungus Blastomyces dermatitidis. This fun-
The Study
On September 21, 2009, a 37-year-old male zoologist
in Indianapolis, Indiana, visited his physician with a 3-day
history of swelling and tenderness of the third digit of his
right hand. He reported having been bitten on the affected
fi nger on August 29 by his pet kinkajou. At the time, the
animal was severely ill with respiratory signs and died
shortly after biting the patient. The wound initially healed
after treatment with antimicrobial ointment. At the physi-
cian visit, the patient was prescribed 2 weeks of doxycy-
cline and amoxicillin/clavulanate and instructed to return if
no improvement was noted.
On September 24, the patient returned with wors-
ening pain. He was hospitalized the next day with fever
(101.0°F), nausea, headache, and continued fi nger tender-
ness. Ascending lymphangitis and swollen, tender, axil-
lary lymph nodes were noted. Except for his leukocyte
count (15,100 cells/mL), laboratory values were within
reference ranges. The patient was treated with intrave-
nous vancomycin and ampicillin/sulbactam, wound inci-
sion, and drainage. Results of blood and wound cultures
were negative. By September 27, the patient’s fever and
lymphangitis subsided. He was discharged and received
amoxicillin/clavulanate and ciprofl oxacin.
The next week the patient returned to the emergency
department with erythematous nodules along his right ba-
silic vein and recurrent ascending lymphadenitis. An in-
fectious disease consultant noted fusiform swelling of the
right middle fi nger, nodular erythematous fl uctuant areas of
the right wrist, swollen and tender axilla, and a nodular area
on the right ankle. A punch biopsy sample from the right
hand showed acute infl ammation and suppurative granu-
lomas of deep soft tissue. Initial stainings were negative
for parasites, fungi, and acid-fast bacilli. Tissue and blood
cultures for aerobic, anaerobic, acid-fast, and fungal organ-
isms were negative, as were serologic results for Bartonella
spp. and Brucella spp.
The patient was readmitted to a local hospital on Oc-
tober 12 with lesions on the right ankle and swelling of the
left ankle. Results of complete blood count with differential,
metabolic profi le, and liver function studies were unremark-
able; additional blood cultures were obtained. The patient was
treated with azithromycin, ciprofl oxacin, and streptomycin.
Axilla aspirate was cultured. On October 16, the patient’s
condition improved, and he was discharged. Blood cultures
obtained during hospitalization were negative. However, a
mold was found growing in the axillary fungal culture.
Tissue from the punch biopsy sample and mold cul-
tures were sent to the Indiana State Department of Public
Health Laboratories, where B. dermatitidis was isolated
from culture on October 21. The patient was prescribed
itraconazole (200 mg 2×/d) for 6 months; he improved rap-
idly, and his infection resolved completely.
Before this illness, the patient had been healthy and
had no recent history of travel or recent history of camping,
digging, or gardening. None of the >60 other exotic animals
he cared for had a history of B. dermatitidis infection.
Kinkajous (Potos fl avus), which are native to South and
Central America, are members of the family Procyonidae.
Leishmania spp. (10), herpesvirus (11), and Salmonella
spp. (12) have been reported in association with kinkajous,
but only Kingella potus has been reported as a zoonotically
transmitted infection resulting from a kinkajou bite (13).
DISPATCHES
268 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 2, February 2011
Author affi liations: Centers for Disease Control and Prevention, At-
lanta, Georgia, USA (J.R. Harris, D.D. Blaney, M.D. Lindsley, S.A.
Zaki, C.D. Paddock, C.P. Drew); Purdue University School of Vet-
erinary Medicine, West Lafayette, Indiana, USA (A.J. Johnson); In-
diana State Department of Health Laboratories, Indianapolis, Indi-
ana, USA (D. Landau); Animalia, Inc., Indianapolis (J. Vanderbush);
and Community Health Network, Indianapolis (R. Baker)
DOI: 10.3201/eid1702.101046

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Blastomycosis in Man after Kinkajou Bite
The kinkajou in this report was a 9-year-old wild-born
female (birth location unknown) brought to the United
States at ≈2 years of age by an animal facility in Texas.
It was acquired by the patient in November 2008 from an
educational organization in Chicago.
The kinkajou lived in a large walk-in enclosure in the
patient’s basement with its male cage mate, which never
displayed similar illness and remains alive. The enclosure
included plastic platforms and a nest box with regularly
cleaned T-shirt bedding, hanging hammock-style fl eece
sleep bags, and wooden branches collected from outside
that were treated regularly with a bleach scrub. The kinka-
jou’s diet included fresh fruits, vegetables, and monkey
crunch biscuits (Mazuri, Lincoln, NE, USA). It was not
handled outside the home, did not roam outside its enclo-
sure, and had no contact with other animals besides its cage
mate. Its medical history was unremarkable. The patient
reported that the kinkajou showed increased respiratory
distress during the 3 days before its death.
The initial necropsy, performed in early September
2009, showed white lesions on the kinkajou’s lungs, which
suggested bacterial pneumonia. However, no bacterium
was cultured. No histopathologic examinations for rabies
were performed at that time. Immediately after necropsy,
the carcass was frozen. After the patient’s diagnosis of
blastomycosis, the carcass was thawed, and lung and oral
mucosal tissue samples were sent to the Centers for Dis-
ease Control and Prevention, Atlanta, GA, USA, for culture
and molecular, histopathologic, and immunohistochemical
(IHC) analysis.
The Centers for Disease Control and Prevention re-
ceived tissue samples from the kinkajou and patient punch
biopsy samples. Sections of skin from the patient showed
extensive epidermal ulceration with superfi cial and deep
perivascular infl ammatory cell infi ltrates comprising pre-
dominantly lymphocytes and macrophages (Figure 1). A fi -
brinopurulent exudate containing neutrophils, erythrocytes,
and necrotic cellular debris tracked from the deep dermis to
the edge of the ulcer. Large, ovoid yeast cells with double-
contoured walls, ≈10–15 μm, were identifi ed in this exudate
by using the Grocott methenamine silver staining technique
and IHC for B. dermatitidis. Polyclonal antibody (Merid-
ian Diagnostics, Cincinnati, OH, USA) used in this assay is
broadly reactive with multiple fungal species, including B.
dermatitidis, making it useful for detection, but not specia-
tion, of yeasts in tissues.
Kinkajou lung tissue was processed for culture and
histopathologic and molecular analysis. Staining of lung
with hematoxylin and eosin (Figure 2) showed numerous
intraalveolar yeasts with double-contoured walls diffusely
fi lling alveolar spaces and associated with infl ammatory
cell infi ltrates (macrophages, lymphocytes, and plasma
cells). Yeasts were also closely associated with surfaces of
the tongue, palate, and buccal mucosae. Use of the Gomori
methenamine silver staining technique and IHC for B. der-
matitidis showed many yeasts in the lungs and fewer in the
liver and on epithelial surfaces of the oral cavity.
DNA was amplifi ed from patient tissue and kinkajou
lung by using non-nested PCR and primers BlastoI and
BlastoII as described (14). Pairwise sequence alignment
showed that the B. dermatitidis BAD-1 promoter region
sequences from the patient isolate and the kinkajou tissue
were indistinguishable.
Conclusions
The successive timing of the kinkajou’s illness and
the patient’s symptom onset suggests that the source of the
patient’s infection was the kinkajou bite. Because asymp-
tomatic animal infections are not known to occur (15), we
believe that the kinkajou likely acquired the infection while
living with the patient.
Immediate necropsy and histopathologic analysis
should be conducted for any animal that bites a human and
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 2, February 2011 269
Figure 1. Histologic appearance of the cutaneous lesion of a man
with blastomycosis. Ulcerated epidermis (A) showing superfi cial
and deep perivascular infi ltrates, predominantly mononuclear
infl ammatory cells. Fibrinopurulent exudate (B) adjacent to the
ulcer, comprising neutrophils, erythrocytes, and necrotic cellular
debris (C), and occasional large yeasts morphologically compatible
with Blastomyces dermatitidis infection (D and E). Hematoxylin and
eosin stain (A, B, and C), Grocott methenamine silver stain (D), and
immunoalkaline phosphatase with antibody against B. dermatitidis
and naphthol fast red with hematoxylin counterstain (E). Original
magnifi cations ×12.5 (A), ×25 (B), and ×100 (C–E).

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then dies, particularly when a lesion develops at the bite
site. This report emphasizes the need for early and com-
plete animal necropsy and consideration of nonbacterial
etiologies when treating a patient with a recalcitrant infec-
tion and a history of an animal bite.
Acknowledgments
We thank Cynthia S. Goldsmith for providing electron mi-
crographs, and health care providers and administrative staff for
their gracious assistance in providing patient information and
follow-up.
Dr Harris is an epidemiologist in the Mycotic Diseases
Branch, National Center for Emerging and Zoonotic Infectious
Diseases, Centers for Disease Control and Prevention. Her re-
search interests include disease surveillance, prevention, and con-
trol for emerging fungal infections.
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Address for correspondence: Julie R. Harris, Centers for Disease Control
and Prevention, 1600 Clifton Rd NE, Mailstop C09, Atlanta, GA 30333,
USA; email: ggt5@cdc.gov
DISPATCHES
270 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 2, February 2011
Figure 2. Histopathologic and electron microscopic appearance of
Blastomyces dermatitidis in kinkajou (Potos fl avus) tissues. A) Lung
showing B. dermatitidis yeast forms fi lling alveolar spaces. Alveolar
septa are indicated by arrows. B) Lung showing yeast forms of B.
dermatitidis. Inset shows broad-based budding of a yeast form, a
major diagnostic feature. C) Lung showing B. dermatitidis yeast.
D) Oral mucosa showing 2 yeast forms of B. dermatitidis closely
associated with the mucosal surface. E) Transmission electron
micrograph showing 3 yeast forms of B. dermatitidis in lung tissue.
Note the thick cell walls and crescent shapes of the yeast (scale
bar = 2 μm). Hematoxylin and eosin stain (A), Grocott methenamine
silver stain (B and inset), and immunoalkaline phosphatase
with antibody against B. dermatitidis and naphthol fast-red with
hematoxylin counterstain (C, D). Original magnifi cations ×400 (A,
B, D) and ×630 (Inset, C).