VETERINARY BLASTOMYCOSIS CASE REPORT FORM
Please fax completed form to Dr. Joni Scheftel at 651-201-5743
A.
DEMOGRAPHIC INFORMATION
B.
CLINICAL SIGNS
C.
LABORATORY INFORMATION
D.
CASE SUMMARY
Owner Name: ____________________________________ Veterinarian Name: _______________________________
Pet's Name: _____________________________________ Institution/Clinic: _________________________________
Species: _______________ Breed: ___________________ City: ___________________________________________
Address: ________________________________________ Phone: ________________
City: __________________________ Zip: _____________
County: _________________________________________
Phone (1): ______________ Phone (2): ______________
Pet's weight (lbs): ________
DOB: ____/____/____
Age: __________________
Sex:
Male
Female
Spayed/Neutered: Yes
No
Pet is primarily:
Indoors Outdoors Both
Symptoms:
Illness onset date:____/____/____
Cough
Yes No
Recovery date:____/____/____
Coughing up blood
Yes No
Previously treated for blastomycosis?
Yes No
Difficulty breathing
Yes No
If yes, when:____/____/____
Non-healing skin sores
Yes No
Lyme disease or anaplasmosis positive? Yes No
Poor appetite
Yes No
Is pet hospitalized?
Yes No
Weight loss
Yes No #lbs.____
Treatment:
None
Fever
Yes No temp. ___F
Itraconazole
Fluconazole
Lethargy
Yes No
Voriconazole
Amphotericin B
Seizures
Yes No
Ketoconazole
Other:_____________
Blindness
Yes No
Did pet die?
Yes No
Lameness/limping
Yes No
If yes, date:____/____/____
Other symptom: __________________________________ Did pet die as a result of blastomycosis? Yes No
If no, cause of death: ________________________
Euthanized?
Yes No
If yes, date:____/____/____
Reason: Poor prognosis Expense of treatment
Both
Other:_____________
Lab name: _______________________________________
Culture:
Smear:
Antigen Testing:
Collection date:____/____/____
Collection date:____/____/____
 Urine  Serum
Result:
Pos Neg
Result:
Pos
Neg
Collection date:____/____/____
DNA probe:
Yes
No
Specimen: ______________________ Result:
Pos Neg
Specimen: ______________________
Value: ________________________
Serology/Antibody:
Histopathology:
Radiology/Imaging:
Collection date:____/____/____
Collection date:____/____/____
Location: ______________________
 AGID
 Elisa
Result:
Pos
Neg
Xray Date:____/____/____
 Comp FX  EIA
Specimen: ______________________ CT Date:____/____/____
Result:
Pos Neg
MRI Date:____/____/____
Titer: __________________________
Results: ________________________
Type of blastomycosis (check all that apply):
Pulmonary, disease present only in the lungs
Extra-pulmonary, no disease in lungs
Disseminated, both pulmonary and extra-pulmonary lesions
Bone
Eye
Skin
CNS
Other location: _________________________________
Minnesota Dept. of Health
PO Box 64975, 625 N Robert St.
St. Paul, MN 55164-0975
Phone: 651-201-5414 | Fax: 651-215-5743
Minnesota Board of Animal Health
625 N. Robert Street
St. Paul, MN 55155-2538
651-296-2942 TTY:1-800-627-3529
3/2016