eng Science and Education Publishing American Journal of Medical Case Reports 2374-216X 2025-06-13 13 4 26 28 10.12691/ajmcr-13-4-2 AJMCR20251342 article Folake Ishola folakeishola26@gmail.com 1 Cassandra Daet 1 Omar Elsheikh 2 Michelle Solik 2 Department of Internal Medicine, Ascension St. Vincent Hospital, Indianapolis, Indiana, USA Department of Infectious Diseases, Ascension St. Vincent Hospital, Indianapolis, Indiana, USA Blastomycosis is a systemic fungal infection known to be endemic in North America, particularly in the Midwest, Central, and Southeastern United States, as well as Great Lakes, Ohio, and Mississippi River Valleys. It is frequently caused by thermal dimorphic fungi, Blastomyces dermatitidis or Blastomyces gilchristii that exist as mold in the environment and transform to yeast in tissues. The infection typically begins in the lungs as the fungal spores or conidia are inhaled from the environment resulting in pulmonary symptoms. Here, we present an atypical form of disseminated blastomycosis in which the patient initially developed cutaneous manifestations followed by pulmonary and liver involvement. The atypical sequence of symptom onset diverges from the classic presentation where pulmonary disease usually precedes extrapulmonary dissemination. He was initially misdiagnosed with multiple rounds of antibiotics and steroids prior to presentation to our facility. This case highlights the importance of considering disseminated fungal infection in the differential diagnosis of cutaneous lesions especially in patients with exposure to endemic regions. Early recognition is crucial for timely diagnosis and management. https://pubs.sciepub.com/ajmcr/13/4/2/ajmcr-13-4-2.pdf blastomycosis disseminated blastomycosis dimorphic fungi cutaneous presentation pulmonary involvement transaminitis itraconazole