SESSION TYPE: Infectious Disease Student/Resident Cases
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: B. dermatitidis, the etiologic agent for Blastomycosis, is a dimorphic fungus that is endemic to the Ohio-Mississippi River Valley. Annual incidence of infection ranges from 0.43-1.40 patients per 100,000 (1). Human infection typically occurs through inhalation of conidia causing pulmonary disease. In solid organ transplant recipients, B. dermatitidis infection is rare and is associated with high mortality and morbidity. Here we present a case of disseminated Blastomycosis in a renal transplant patient.
CASE PRESENTATION: The patient was a 68 year old male with a history of a single nonrelated living kidney transplant three months prior to presentation with a post-operative course notable for CMV encephalitis and a perinephric lymphocele three weeks prior to admission. He was admitted for altered mental status, fevers and abdominal pain. Admission exam was significant for confusion, respiratory accessory muscle usage, and diminished breath sounds at the lung bases. An abdominal CT showed evidence of recurrence of a perinephric lymphocele, diffuse reticular nodularities, and a confluent consolidation in the right lower lobe. Subsequent fluid from the lymphocele grew VRE. Despite treatment with Daptomycin, he developed acute hypotension. A repeat CT showed worsening bilateral reticular 3-4 mm lung nodules, ascities, and portal hypertension. A paracentesis and bronchoscopy were performed. Both the ascitic fluid and BAL showed broad based buds later identified as Blastomycosis dematitidis. Subsequent urinary B. dermatitidis antigen was also above the limit of quantification. Therapy with Liposomal Amphotericin B was started but progressive multiorgan failure ensued. The patient’s mental status improved to permit participation in treatment decisions, and the patient elected to proceed with palliative measures.
DISCUSSION: Disseminated Blastomycosis is a rare complication following solid organ transplant. By one case series, the cumulative incidence is 0.14% (8/9104) (1) with an associated mortality of up to 67% in patients with ARDS. Median time of disease onset following transplant is 24 months. Cutaneous disease is the most frequently encountered form of dissemination. There have been only four prior reports of peritoneal Blastomycosis in the literature (2), and dissemination was attributed to hematogenous spread.
CONCLUSIONS: This appears to be the first reported case of peritoneal Blastomycosis in a solid organ transplant recipient.
1) Gauthier GM, Safdar N, Klein BS, Andes DR.Blastomycosis in solid organ transplant recipients. Transpl Infect Dis. 2007 Dec;9(4):310-7.
2) MacDonald HJ, Fong IW, Gardiner GW, Soutter DI. Splenic abscess caused by Blastomyces dermatitidis in association with peritoneal involvement: case report and review. Clin Infect Dis. 1992 Jan;14(1):348-9.
DISCLOSURE: The following authors have nothing to disclose: Srinath Sriram, Mohammed Mohammed, David Sonetti
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