A CASE OF BLASTQMYCETIC—DERMATFfer- 
OF THE LEO. 
LUDVIG HEKTOEN, M.D. 
CHICAGO. 
I am greatly indebted to Prof. J. B. Murphy and Dr. 
W. E. Coates for allowing me to use the clinical history 
of, and the material from, the following case of blasto- 
mycetic infection of the skin of the leg. 
Clinical History.—Mrs. W., aged 64, married, with an 
uneventful family and personal history, was admitted 
into Professor Murphy’s clinic, Nov, 10, 1897, on ac- 
count of a lesion on the right leg, of which she gave the 
following account: Four months previously a small 
pimple appeared of itself, on the posterior surface of the 
lower third of the right leg; three or four days later a 
second pimple sprang up; both seemed to contain clear 
fluid. Gradually the two fused into one larger mass, 
which slowly enlarged. After one month the swelling 
was opened by a doctor and a bloody fluid escaped, after 
which it slowly “dried up.” In a few weeks it reopened 
and ulcers would form, heal up, and appear again, the 
swelling slowly increasing. When she appeared in Pro- 
fessor Murphy’s clinic there was a circular, elevated, 
cauliflower mass, as large as a silver dollar, with an ir- 
regularly ulcerated and red surface. The growth was 
regarded as probably carcinomatous and removed by a 
circular incision running 2 cm. outside of its margins, 
the subcutaneous fat and superficial fascia being dis- 2 
sected away continuously with the diseased tissue. The 
defect was covered by a plastic operation. Primary 
union followed. The subsequent history is not 
known. 
Description of Gross Specimen.—The part removed 
was mounted in glycerin-jelly and placed in the museum 
of the College of Physicians and Surgeons. It now- • 
March 26, 1899—presents the following appearances 
(Fig. 1) : There is an ovoid raised area, 4by 5 cm. in 
the principal diameters, surrounded by a strip of 
healthy-looking skin from 1 to 2 cm. wide, the under 
surface being composed of yellow subcutaneous fat. The 
central area is quite evenly and abruptly raised above 
the level of the surrounding skin to the extent of about 
.5 cm., its margin round, the sides partly covered by 
epidermis, the surface marked by larger and smaller 
elevations and depressions and deeper furrows, which 
give the surface somewhat of a cauliflower appearance; 
the surface is yellowish in color, showing also several 
reddish spots which in some places correspond to super- 
ficial erosions. On section the raised part seems to be 
made up of a rather homogeneous, now yellowish tissue 
which is quite sharply and evenly demarcated from the 
subcutaneous fat tissue on a level with the corium of the 
surrounding healthy skin. 
Histologic Examination.—The tissue was fixed in 
formalin and alcohol, imbedded in paraffin, and stained 
with hematoxylin and eosin, polychrome methylene 
blue, etc. 
The sections include part of the elevation of the skin 
and underlying tissues; at its highest point the elevation 
rises .5 cm. above the level of the healthy skin present 
near one edge of the sections. The larger part of the 
nodule and the adjacent skin from which the nodule 
rises gradually are covered by a moderately thickened 
epithelial layer, the horny stratum of which is rather 
coarse and thicker than nsual; part of the elevation is 
without any normal epithelial covering and presents ir- 
regular, somewhat crater-shaped depressions; the mar- 
gins of the ulcers and the immediately adjacent sur- 3 
faces are composed of irregular masses of epithelial cells 
and intervening elevations which contain inflammatory 
tissue, necrotic debris, leucocytes and fragments of 
horny matter. The elevation is due principally to a 
marked epithelial hyperplasia in the form of irregular, 
branching bands and masses, as well as separate nests 
the centers of which are generally more or less hornified. 
In many places these epithelial proliferations consist 
largely of typical prickle cells. 
The histologic resemblance to fiat-celled carcinoma is 
often marked (Fig. 2). This proliferation appears to 
Pig. I.—Photograph of blastomycetic lesion of the skin of the leg. 
One-third natural size. 
have started from the epithelium about the crater- 
shaped ulcers, and to have progressed downward as well 
as laterally, without having become united with the over- 
lying intact epidermis, the thickening of which is large- 
ly due to polypoid downgrowths of the interpapillary 
portions. Between the epithelial masses and bands is a 
very vascular and cellular connective tissue the seat of 
a marked leucocytic and other cell infiltration; in some 
places there are more focal accumulations of leucocytes 
constituting miliary abscesses. Similar miliary ab- 4 
scesses occur also in the centers of masses of epithelial 
cells. The size of these abscesses varies greatly; they are 
usually round or irregularly oval, and in the case of the 
intra-epithelial abscesses the surrounding epithelial 
layers are usually composed of greatly flattened cells. 
Scattered polymorphonuclear leucocytes occur also with- 
in and between the epithelial cells. There is also consid- 
erable cellular infiltration of the fibrous tissue below and 
to the sides of the epithelial proliferation; the deep 
margins of the sections are formed by normal fat 
tissue. 
Fig. 2.—Showing epithelial proliferations, superficial ulcers and mili- 
ary abscesses. 60.* 
Examined with higher powers, the miliary abscesses 
are found to in some instances contain one or two typical, 
doubly contoured blastomycetes, with granular and occa- 
sionally vacuolated protoplasm. (Fig. 3.) The organ- 
isms are round, about 12 microns in diameter ; distinct 
budding forms are present; some of the bodies contain 
one or more vacuoles of irregular size and outline. Iso- 
* Figs. 2 and 3 were used in the British Jour, of Derm., 1899, No. 129, 
Vol. xi. 5 
lated organisms have also been found outside of the 
typical miliary abscesses, lying in the granulation tis- 
sue and usually surrounded by a few polymorphonu- 
clear leucocytes, which seem to be gathering around the 
blastomycetes. Some of the organisms are stained very 
distinctly in the methylene blue specimens. 
In addition to the densely packed polymorphonuclear 
leucocytes, the miliary abscesses also contain cells with 
oval, more vesicular nuclei and occasional multinuclear 
giant cells of the tuberculous type. Some of the giant 
cells contain quite typical organisms. 
Fig. 3.—Double-con toured,vacuolated, budding blastomyces n a miliary- 
abscess. X 750. 
The inflammatory tissue between the epithelial masses 
and in the corium proper and the subcutaneous tissue 
contains quite large accumulations of, as well as scat- 
tered, typical plasma cells, which in their reaction to 
methylene blue as well as in all other details correspond 
to the classic type of this cell; in the hematoxylin sec- 
tions the finely granular protoplasm of the plasma cell 
stains a light bluish tinge. New-formed vessels in which 
are lymphocytes, plasma cells and polymorphonuclear 6 
leucocytes are present; some of these cells are seen pass- 
ing through the vessel walls. In some vessels the lumen 
is packed with lymphocytes only. There are also not a 
few eosinophile cells, both within and outside the ves- 
sels, a few large cells with vesicular nuclei and a cyano- 
phile, granular protoplasm which the polychrome meth- 
ylene blue stain seems to show are mast-cells, and, final- 
ly, occasional multinuelear giant cells of the tubercu- 
lous type. Tubercle bacilli are not present in the sec- 
tions stained with earbol-fuchsin. 
Not a few karyokinetic figures are seen in the cells of 
the granulation tissue, and occasional circular groups of 
hyaline spheres are also present. 
This case has already been considered in an article by 
Hyde, Hektoen and Bevan.1 The case merits special 
notice because the clinical resemblance of the growth to 
carcinoma and its histologic resemblance on the one 
hand to carcinoma and on the other to tuberculosis em- 
phasize well the importance and also the difficulty of the 
diagnosis of chronic blastomycosis of the skin. The 
clinical aspects of blastomycetic dermatitis have been 
fully considered by Hyde in the article just mentioned. 
I wish to emphasize the histologic characteristics of the 
forms of chronic cutaneous blastomycosis of which the 
above ease is a good example. The marked epithelial 
proliferation in the form of carcinomatoid masses and 
downgrowths, associated with the formation of em- 
bryonal cells in the stroma, with giant cells and much 
leucocytic infiltration, diffuse as well as focal, in the 
form of miliary abscesses between as well as within the 
epithelial masses, constitute the characteristic histologic 
picture of this form of mycosis, the blastomycetic 
nature of which is definitely established by finding the 
characteristic, double-contoured, budding, yeast-like 
organisms in the lesions, usually in the miliary abscesses. 
In these respects the cases of Gilchrist and Stokes, Wells, 
Hyde, Hektoen and Bevan, and of Owens, Eisendrath 
and Ready2, the above ease and two unpublished cases, 
the specimens from which were kindly shown me by Dr. 
W. E. Coates and Dr. M. Herzog—a courtesy for which I 7 
am very thankful—resemble each other completely, and 
they constitute a quite well-defined clinical and histologic 
group which is easily separated from the distinctively 
suppurating and destructive form of blastomycosis as il- 
lustrated by Busse’s case, the dermatologic features of 
which have been especially studied by Buschke,3 and by 
the case briefly described by Hessler.4 And yet it ap- 
pears not unlikely that the cases of chronic blastomy- 
cetic dermatitis such as the one now reported may be 
produced by organisms which differ so much in their 
characteristics that they must be regarded as distinct 
varieties. Thus the blastomyces dermatitidis described by 
Gilchrist and Stokes differs considerably from the or- 
ganism in a blastomycetic dermatitis which I studied.5 
But the classification and the botanic relations of the so- 
called blastomycetes are as yet in a rather unsettled com 
dition. While the histologic structures of chronic cutan- 
eous blastomycosis resemble in some ways carcinoma to 
such an extent that errors might easily be committed in 
microscopic diagnosis—a fact of considerable interest 
in connection with recent efforts to demonstrate that 
carcinoma and sarcoma are caused by yeast, or other 
fungi—yet none of the cases of blastomycetic dermatitis 
so far described have pursued the clinical course charact- 
eristic of carcinoma to the extent that regional or general 
carcinomatous metastases have been noted. The possibil- 
ity that a genuine carcinoma may originate in the lesions 
of cutaneous blastomjnosis is of course apparently no 
more remote than the development of carcinoma upon 
the basis of cutaneous tuberculosis. The cases of blasto- 
mycetic dermatitis are as yet too few and the periods of 
observation too short to make many dogmatic state- 
ments. Thus nothing definite can as yet be said con- 
cerning the mode of infection, except that from its usual 
localizations it appears to occur from without. I have 
made a number of experiments on animals, with the 
organism isolated from the ease under the care of Drs. 
Hyde and Bevan, looking to the production of a primary 
cutaneous process, but so far without success. 8 
1. A Contribution to the Study of Blastomycetic Dermatitis: British 
Jour, of Derm., 1899, xi. 
2. Annals of Surgery, Nov., 1899. 
3. ÜberHefenmykosenbeiMenchenund Thieren: Volkmann’s Samm- 
lung Klin. "Vortrage, 1898, 218: Über Hautblastomykoses, Verb. d. vi; 
Deutschen Dermatolog. Congresses, 1898. 
4. Indiana Medical Journal, 1898; Journal, 1898. 
5. Journal of Experimental Medicine, 1899, iv, 261. 
BIBLIOGRAPHY. 
REP RIM TER FROM 
THE'JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 
DECEMBER S, #,9.9,