Cutaneous, Intranasal Blastomycosis Infection in Two Patients from Southern West Virginia: Diagnostic Dilemma

: Blastomycosis is a dimorphic fungus caused by the species of Blastomyces dermatitidisand Blastomyces gilchristii, which are endemic to the Ohio River and Mississippi River Valleys. It is commonly found in soil or decomposing wood. It is capable of infecting both immunocompromised and immunocompetent patients via the respiratory tract by inhaling conidia, where it may remain asymptomatic for a prolonged period of time. Extrapulmonary complications can occur in disseminated disease due to haematogenous spread from the lungs to other organ systems. Haematogenous dissemination from the lungs occurs most commonly to the skin. Although rare, primary cutaneous blastomycosis can also occur with direct inoculation through the trauma of the skin. Patients presenting with cutaneous blastomycosis are often misdiagnosed with malignant neoplasms and may not be appropriately managed until further testing and tissue biopsy. Currently, there are only four previous case reports of blastomycosis presenting in the intranasal region. We report two cases of cutaneous blastomycosis of the nasal passages and upper lip with pulmonary manifestations in Southern West Virginia. These patients first presented with cutaneous symptoms, which were originally treated for melanoma and squamous cell carcinoma and were later diagnosed with systemic blastomycosis.