blastomycosis is a systemic mycotic infection caused by the dimorphic fungus blastomyces dermatitidis , ( anamorph , ajellomyces dermatitidis teleomorph ) . in natural conditions , blastomyces grows in a saprophytic mycelial form that produces infective spores ( aleuriocornidia ) sexually . infection in body tissues occurs when these conidias are phagocytosed by pulmonary macrophages , and spreaded to the pulmonary interstitium . at body temperature , the yeast form is characterized by a round , 520  m diameter , broad - based structure with a thick , refractile , and double contoured cell wall , . the disease may localize in the lungs or may spread hematogenously or lymphatically to other organs . systemic pyogranulomatous disease is most commonly reported in dogs , humans and infrequently reported in cats . infected animals showed systemic illnesses such as anorexia , lethargy , respiratory distress , skin lesions and weight loss , . the endemic areas of blastomycosis are north america , ohio and mississippi river valleys , north central wisconsin and the northern region of ontario . the organisms favor growing in moist , acidic soil enriched with decaying vegetation or animal excreta . the soil near lakes , rivers or streams is considered a risk location for infection , . other than the endemic regions , blastomycosis has been reported in africa , india , europe , and central america , , , , , . there is one case report each from israel and saudi arabia , and there are many human case reports in india , but only five cases have been conclusively proven to be blastomycosis , . as of today , there are no confirmed cases of human exposure in thailand . chest radiographs support the radiographic changes of lung tissue , which are diffuse miliary or nodular interstitial pattern . serology antigen detections are agar gel immuno diffusion ( agid ) , radio immuno assay ( ria ) and enzyme immunoassay ( eia ) with a sensitivity of 17.490 , 92 and 76.1% respectively . all serology tests have 100% specificity , and ria can detect antibody up to1545 day post infection . treatment of blastomycosis is depended on the severity of disease . for significant pulmonary - involved dogs and cats , the recommended treatment are amphotericin b at the dose of .51  mg / kg ( dogs ) and .25  mg / kg in cats intravenously with itraconazole 510  mg / kg for the first 47 days , and follow by itraconazole 510  mg / kg for 46 months . in less severe cases , the recommended treatment is itraconazole at a dose of 510  mg / kg twice a day for at least 60 days . the treatment should be continued until 1 month post radiographic resolution of lung tissue , , , . pseudomycetoma , an atypical form of dermatophytosis , is a deeper dermal and/or subcutaneous infection caused by dermatophytes in cats and dogs . it has been indicated that persian cats are predisposed to dermatophytosis due to ineffective grooming of the long hair coat , the cutaneous microenvironment or immunological deficits , . lesions of dpm are not restricted to epidermal structures , because the organisms can invade the dermal tissue and rupture the follicular structure causing multifocal nodular dermatitis . diagnosis of dpm is made by wood 's lamp and trichograms of broken hairs which architecture are effaced by fungal hyphae . cytology of fine needle aspiration demonstrates numerous degenerate neutrophils , activated macrophages , multinucleated giant cells and fungal hyphae . histopathology will confirm the diagnosis with coalescing foci of pyogranulomatous inflammation surrounding multiple , irregular basophilic hyphae - like elements in a sparse , granular , faintly eosinophilic matrix . pcr analysis can be performed to confirm the identification of the organism by using biopsy samples for fungal dna extraction , . dermatophytic pseudomycetoma infection can be difficult to manage and the prognosis is poor . the lesions often recur after surgical excision and the outcome with surgical excision and concurrent use of antifungal treatments ( griseofulvin , ketoconazole , and itraconazole ) has been variable , . the purpose of this case report is to report blastomycosis concurrent with dermatophytic pseudomycetoma in an indoor persian cat , which is also the first case report of blastomycosis in thailand . a 3-year - old male intact persian cat was referred to the dermatology clinic with 2 months history of chronic skin lesions . initial treatment was oral itraconazole at a dose of 5  mg / kg for 1 month , resulting in some improvement . however , the treatment was discontinued 1 month before referral . according to the owner , the owner and the other two cats at the same household had no skin lesions . the nodules at chin area had draining tract with bloody discharge ( fig . 1a and 1b ) . cytological examination of the draining nodule at the chin revealed a large number of coccoid bacteria , neutrophils , macrophages , and branching septate fungal hyphae . from the history of recurrent dermatophyte infection , a tentative diagnosis of dermatophytic pseudomycetoma with deep bacterial and/ or deep fungal infection was suspected . specimen for histopathology samples was fixed in 10% neutral buffered formalin , which was stained with haematoxylin and eosin stain ( h&e ) and periodic acid - schiff stain ( pas ) . chest and abdominal radiograph and abdominal ultrasound were performed at the initial exam and the results were within normal limits . feline leukemia and immunodeficiency tests were negative . the complete blood count , liver enzymes ( alt and alkp ) , and renal panel tests ( bun and creatinine ) were within normal limits . on day 0 , the cat was treated with oral antibiotic ( amoxicillin and clavulinic acid ) at a dose of 20  mg / kg orally twice a day , and topical treatment with 3% chlorhexidine and climbazole mousse pending histopathology result . on day 3 , the results of histopathology revealed severe chronic multifocal to coalescing granulomatous dermatitis and panniculitis , with intralesional budding yeasts , consistent with blastomycosis and intralesional fungal hyphae , consistent with dermatophyte pseudomycetoma ( fig . 2a and 2b ) . the diagnosis of concurrent blastomycosis and dermatophyte pseudomycetoma was made . the treatment was changed to oral itraconazole 10  mg / kg daily . on day 7 , the cat died at home . there were multiple ulcerated and proliferative cutaneous nodules , estimated from 2 to 5  cm , on the face , chin , neck , and body . microscopic examination of the proliferative skin nodules was consistent with the biopsy results ( figs . 3b and 3c ) . histopathology of lung tissues revealed alveolar collapse with presence of minimal to moderate fluid in alveolar lumen . b : photograph of the skin nodules at chin area with draining tract and bloody discharge.fig . 2a : photomicrograph of broad - based budding yeasts of blastomyces sp . ( blue arrow ) : h & e ) . b : photomicrograph of intralesional yeasts with thick , refractile , and double contoured cell wall ( blue arrow ) : h & e ) . c : photomicrograph of broad - based budding yeasts and thick , refractile , and double contoured cell wall ( black arrow ) and branching septate hyphae ( blue arrow ) , pas . ( for interpretation of the references to color in this figure legend , the reader is referred to the web version of this article).fig . 3a : photograph of the cat ( hair - clipped ) with multiple ulcerated and proliferative skin nodules . b : photomicrograph of the granuloma showing multifocal to coalescing granulomatous panniculitis containing numerous septate hyphae ( blue arrow ) , epithelioid macrophages , plasma cells , neutrophils , and multinucleated giant cell . h & e. c : photomicrograph of the septate hyphae in the granulomatous lesion ( black arrow ) , pas . ( for interpretation of the references to color in this figure legend , the reader is referred to the web version of this article).fig . b : photograph of the skin nodules at chin area with draining tract and bloody discharge . b : photomicrograph of intralesional yeasts with thick , refractile , and double contoured cell wall ( blue arrow ) : h & e ) . c : photomicrograph of broad - based budding yeasts and thick , refractile , and double contoured cell wall ( black arrow ) and branching septate hyphae ( blue arrow ) , pas . ( for interpretation of the references to color in this figure legend , the reader is referred to the web version of this article ) . a : photograph of the cat ( hair - clipped ) with multiple ulcerated and proliferative skin nodules . b : photomicrograph of the granuloma showing multifocal to coalescing granulomatous panniculitis containing numerous septate hyphae ( blue arrow ) , epithelioid macrophages , plasma cells , neutrophils , and multinucleated giant cell . h & e. c : photomicrograph of the septate hyphae in the granulomatous lesion ( black arrow ) , pas . ( for interpretation of the references to color in this figure legend , the reader is referred to the web version of this article ) . in order to confirm the histopathological result , a polymerase chain reaction ( pcr ) was performed twice from formalin - fixed , paraffin - embedded ( ffpe ) tissue from the chin area . in brief , the 10 ffpe section ( 5  m thickness ) were deparaffinized with 1  ml xylene and washed with absolute alcohol . the samples were subjected to dna preparation using the conventional method : glass beads and phenol extraction protocol . these genomic dnas were amplified in the inter - transcribed spacer region by universal its1 and its4 primers ( its1 5'-tcc gta ggt gaa cct gcg g-3 ' and its4 5'-tcc tcc gct tat tga tat gc-3 ' ) . the amplicons were purified by a pcr purification kit ( qiagen , usa ) and sent for sequencing ( 1st base laboratory , malaysia ) . the sequences from the first collected specimen at chin area revealed 98% homology to ajellomyces dermatitidis ( blastomyces dermatitidis , anamorph ) and sequences from pseudomycetoma area were 98% homology to microsporum canis . this is the first case report of blastomycosis and concurrent dermatophyte pseudomycetoma in a persian cat from the central part of thailand . the initial diagnosis was made from histopathology of the antemortem lesion from nodules at the chin . since south - east asia is not an endemic area of blastomycosis , pcr analysis of formalin embedded tissues from the same ante - mortem lesion was performed . the infected cat died within one week and histopathology of necropsy samples supported the diagnosis . according to the owner , the infected cat was bought from a breeder in bangkok , thailand at the age of 3 months , and was always in poor body condition . at the age of 6 months , the cat was suspected to have a dermatophyte infection , and was treated periodically with oral itraconazole and medicated shampoo containing 2% chlorhexidine and 2% miconazole , which resulted in some improvement . this cat might have a defective cell mediated immune system leading to susceptibility for dermatophyte infection when it was a kitten . dermatophyte pseudomycetoma ( dpm ) is associated with breed related immunodeficiency or an aberrant immune response to dermatophytes . with the weak cell mediated immune system , this persian cat was infected by dpm followed by blastomycosis . the reservoir for the blastomycosis was suspected to be soil , where the organism grows in a saprophytic mycelial form . this persian cat was an indoor cat , but liked to sit by the window where the owner placed a flowerpot . the owner always brought the potting soil from different flower shops and changed the soil at least three times per year . published the retrospective report of clinical aspects of natural infection with blastomyces dermatitidis in 8 cases of cats . five cats were reported to be indoor - outdoor cats , and one was an indoor only cat , and the status of the remaining two cats was unknown . respiratory tract signs were evident in six of the eight cats , skin lesions were evident in seven cats , and five cats had one or more non - ulcerated dermal nodules . investigated the environment of five urban , indoor cats diagnosed at three veterinary clinics between march 3-july 13 , 2005 in suburban chicago , illinois , by owner interviews , site visits , and environmental cultures for blastomyces dermatitidis . the study suggested that the acquisition of blastomyces dermatitidis was from the home site environment . it was assumed that the fungus had been growing in the nearby environment and possibly spread into close proximity to the home by windborne dust . the mode of transmission for this persian cat was suspected to be from inhalation of aerosols containing infective spores . the spores entered the terminal airways and disseminated via the blood or lymphatic system to skin . necropsy of the lung tissue both gross and histopathology samples did not show evidence of granulomatous inflammation or yeast organism . the author suspected that the rapid dissemination of the infectious agents to other organs , such as skin after inhalation , might make it difficult to detect lung lesions on radiographs . for this persian cat , we assumed the same reason , or that there was not enough time to develop lesions in the lung tissue . the change of hepatocytes might be from the prolonged treatment of itraconazole when the cat had a recurrent dermatophyte infection . due to the indoor status of the cat , an autochthonous blastomycosis in thailand is suspected . the owner of this cat was educated about how the reservoir of the mycelial form of the organism might be from the potting soil . the yeast phase of the organism can not be transmitted through aerosols between humans , between animals , or from animals to humans . therefore , this disease is not considered contagious or zoonotic , , . according to the author 's knowledge , this is the first case report of blastomyces dermatitidis concurrent with dermatophyte pseudomycetoma infection in a persian cat from thailand and south - east asia .
this is a case report of concurrent of blastomycosis and pseudomycetoma in a 3 year - old persian cat from bangkok , thailand . 
 histopathology from antemortem and postmortem samples revealed blastomycosis and dermatophyte pseudomycetoma . 
 the pcr analysis of the formalin - embedded tissue of antemortem sample confirmed that blastomycosis was caused by blastomyces dermatitidis . 
 dermatophyte infection was caused by microsporum canis . according to the author 's knowledge , 
 this is the first case of blastomyces dermatitidis and dermatophyte pseudomycetoma in south - east asia .