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Blastomycosis occurs most often in men infected during occupational or recreational activities out of doors and in a geographically limited area of the south central and midwestern United States and Canada Disease usually occurs in immunocompetent individuals Pulmonary infection is most common and may be asymptomatic When dissemination takes place, lesions are most frequently seen in the skin, bones, and urogenital system Cough, moderate fever, dyspnea, and chest pain are common These may resolve or progress, with bloody and purulent sputum production, pleurisy, fever, chills, loss of weight, and prostration Radiologic studies, either chest radiographs or CT scans, usually reveal pulmonary infiltrates and enlarged regional lymph nodes, though less commonly than in histoplasmosis or coccidioidomycosis Raised, verrucous cutaneous lesions that have an abrupt downward sloping border are usually present in disseminated blastomycosis Bones often the ribs and vertebrae are frequently involved Lesions appear to be both destructive and proliferative on radiography Epididymitis, prostatitis, and other involvement of the male urogenital system may occur Central nervous system involvement is uncommon Although they do not appear to be at greater risk for acquisition of disease, infection in HIV-infected persons may progress rapidly, with dissemination common Laboratory findings usually include leukocytosis and anemia, though these are not specific The organism is found in clinical specimens, such as expectorated sputum or tissue, as a thick-walled cell 5 20 mcm in diameter that may have a single broad-based bud It grows readily on culture Serologic tests are not well standardized A urinary antigen test is available, but it has some cross reactivity with Histoplasma; consequently, its usefulness in diagnosis and in assessing response to therapy is unclear Itraconazole, 100 200 mg/d orally for at least 2 3 months, is the therapy of choice for nonmeningeal disease, with a response rate of over 80% Amphotericin B, 03 06 mg/kg/d intravenously for a total dose of 15 25 g, is given for treatment failures or cases with central nervous system involvement Clinical follow-up for relapse should be made regularly for several years so that therapy may be resumed or another drug instituted.

Kauffman CA et al Endemic mycoses: Blastomycosis, histoplasmosis, and sporotrichosis Infect Dis Clin North Am 2006 Sep; 20(3):645 62 [PMID: 16984873]

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As we discussed in 7, C# divides the world of types into value types and reference types. All intrinsic types (such as int and long) are value types. Instances of classes (objects) are reference types. When you pass a value type (such as an int) into a method, a copy is made. When you make changes to the parameter, you re actually making changes to the copy. Back in the Run( ) method, the original integer variables first and second are unaffected by the changes made in DoubleInt( ). What you need is a way to pass in the integer parameters by reference so that changes made in the method are made to the original object in the calling method. When you pass an object by reference, the parameter refers to the same object. Thus, when you make changes in DoubleInt( ), the changes are made to the original variables in Run( ). You do this by prefacing the parameters with the keyword ref.

The term mucormycosis (zygomycosis, phycomycosis) is applied to opportunistic infections caused by members of the genera Rhizopus, Mucor, Absidia, and Cunninghamella Predisposing conditions include diabetic ketoacidosis, chronic renal failure, desferoxamine therapy, and treatment with corticosteroids or cytotoxic drugs These organisms appear in tissues as broad, branching nonseptate hyphae Biopsy with histologic examination is almost always required for diagnosis; cultures are frequently negative Invasive disease of the sinuses, orbits, and the lungs may occur Widely disseminated disease has been more commonly seen recently in patients who have received aggressive chemotherapy and broad-spectrum antifungal prophylaxis The diagnosis should be considered in immunocompromised patients with black necrotic lesions of the nose or sinuses or with new cranial nerve abnormalities Without treatment, cerebral invasion may ensue A prolonged course of high-dosage amphotericin B (1 15 mg/ kg/d intravenously) or a lipid preparation of amphotericin B should be started early Based on in vitro susceptibility and reports of successful salvage therapy, there may be a role for posaconazole in the treatment of these infections, but other azoles are likely to be ineffective Control of diabetes and other underlying conditions, along with extensive repeated surgical removal of necrotic, nonperfused tissue, is essential Even when these measures are introduced in a timely fashion, the prognosis is poor, with a 30 50% mortality rate for localized disease and higher rates in disseminated cases

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