Search

Patients are commonly referred to general surgery clinics for evaluation of soft-tissue masses of the trunk and extremities. The primary goal of surgical referral is to confirm the presence of a mass, to assess the need for additional imaging and/or testing, and to gauge amenability to surgical biopsy, whether incisional or excisional. This is a case of a 67-year-old woman who was referred to surgery clinic for a small soft-tissue mass near her left elbow that had increased in size and pain over the past year. The mass had been present for several years. After MRI imaging revealed a nonspecific process, an excisional biopsy was performed. Following a careful review of the patient’s history, risk factors, and histological results, a diagnosis of localized subcutaneous Histoplasma capsulatum var. capsulatum infection was made. Without signs or symptoms of active, systemic disease, no further treatment was recommended. The patient was provided risk factor counseling for symptoms or signs of active histoplasmosis and outpatient follow-up. Histologically, most masses will return as benign and mesenchymal in origin. However, soft-tissue masses may arise from uncommon etiologies and a broad differential is needed to ensure appropriate management and recommendations.

Pulmonary blastomycosis is an uncommon but serious fungal infection endemic in Wisconsin. Clinician awareness of the protean presentations of this disease may reduce diagnostic delay. This study addressed the diagnostic accuracy of physicians responding to case vignettes of pulmonary blastomycosis and the primary care differential diagnosis of this disease.Eight pulmonary blastomycosis cases were developed from case files. From these, 2 vignettes were randomly selected and mailed to primary care physicians in the Wisconsin Network for Health Research. Respondents were asked to list the 3 most likely diagnoses for each case.Respondents listed Blastomycosis as the most likely diagnosis for 37/227 (16%) case vignettes, and 1 of the 3 most likely diagnoses for 43/227 (19%). When vignettes included patient activity in counties with an annual incidence rate of blastomycosis greater than 2/100,000, compared to counties with lower incidence rates, diagnosis was more accurate (28/61 [46%] vs 15/166 [9%]; P0.001). Physicians with practice locations in counties with annual blastomycosis incidence rates2/100,000 listed blastomycosis more commonly than physicians from other counties (16/36 [44%] vs 27/177 [15%]; P0.001). This difference in accurate diagnosis remained significant in a multivariate model of practice demographics. Based on responses to the vignettes, pneumonia, cancer, non-infectious pulmonary disease, and tuberculosis emerged as the most-frequently noted diagnosis in the differential diagnosis of blastomycosis.Blastomycosis was not listed as 1of 3 primary diagnoses in a majority of cases when Wisconsin primary care physicians considered case vignettes of actual pulmonary blastomycosis cases. Diagnosis was more accurate if the patient vignette listed exposure to a higher incidence county, or if the physician practiced in a higher incidence county. In Wisconsin, failure to include blastomycosis in the differential diagnoses of illnesses associated with a wide variety of pulmonary symptoms suspected to represent infectious or non-infectious pulmonary, cardiac, or neoplastic disease, regardless of geographic exposure, could result in excess morbidity or mortality.