LAUSR

A 27 year old African man, who arrived in Italy from Senegal four months before, was admitted after several weeks of lowgrade fever and mild pain, mainly localized in the inferior left abdominal quadrant and at the root of the thighs bilaterally. A preceding disseminated tuberculosis has been reported but no concurrent conditions of immunosuppression nor HIV infection were diagnosed. The patient seemed severely suffering and cachectic. CT-scan noticed multiple large and confluent fluid collections deeply in both psoas muscles (up to 9 cm), associated with multiple bone lytic lesions of the pelvis Figures 1, 2, and 3. The clinical conditions got worse, despite the broad-spectrum antibacterials (rifampicin, doxycycline and ciprofloxacin combined therapy). Percutaneous drainage was unsuccessful because the fluid was too thick. Therefore, the collections were drained sequentially through a retroperitoneal surgical approach. The fluid samples tested positive for Blastomyces dermatitidis, through molecular amplification and sequencing of the 18S region. Oral itraconazole (200 mg 3 times/day for 3 days, and then 200 mg bid) therapy prolonged for six months led to progressive clinical improvement, until complete recovery. Blastomycosis is a rare fungal infection mainly responsible for pulmonary disease. Less than half of symptomatic cases develop an extrapulmonary