SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Blastomycosis is a systemic fungal infection of Blastomyces dermatitidis, with primarily pulmonary involvement, presenting as asymptomatic or symptomatic disease. Pulmonary blastomycosis is most severe in immunocompromised hosts. We describe an atypical fatal presentation of severe pulmonary blastomycosis in an immunocompetent man.
CASE PRESENTATION: 31-year old, HIV(-) man presented after 10-day community acquired pneumonia (CAP) treatment, with dyspnea and oxygen desaturation. He required orotracheal intubation and mechanical ventilation for acute hypoxic respiratory failure (AHRF). Imaging revealed bilateral air space disease. He was empirically treated for severe bacterial CAP. AHRF and sepsis worsened; high FiO2 requirements and acute respiratory distress (ARDS) resulted. End organ damage ensued, requiring dialysis, vasopressors, inhaled nitric oxide and 1.0 FiO2 to maintain SPO2 >90%. Ongoing desaturation persisted, prompting venovenous extracorporeal membrane oxygenation (VV ECMO), targeting tissue perfusion and lung protection. Transient SPO2 response permitted lower FiO2 delivery. Overall clinical status remained unchanged. Amphotericin and oseltamivir were started. Urine Histoplasma and Blastomyces antigen; Adenovirus 14 serology; bacterial and fungal cultures of bronchoalveolar lavage fluid (BALF) were obtained. On day 5, during ECMO oxygenator membrane replacement, transient bradycardia and hypoxia resulted cardiopulmonary arrest, unsuccessful resuscitation and death of patient. Later, BALF revealed heavy yeast, and antigens to Blastomyces and Histoplasma. Blastomycosis was confirmed by lung cultures at autopsy. Gross examination of lungs showed coalescing tan nodules with focal necrosis. Microscopy and Grocott-Methenamine silver staining confirmed pyogranulomatous blastomycosis via multinucleated giant cells, fungal elements, adjacent necrotic debris, and fibrosis.
DISCUSSION: B. dermatitidis is a dimorphic conidial fungus in soil, which upon inhalation results pulmonary pyogranulomas. Incubation period is typically 3-6 weeks, and upto several months. Skin, bones, and genitourinary infections result via hematogenous spread of fungus. Symptoms range from asymptomatic, to severe pulmonary, or systemic diseases.
CONCLUSIONS: Despite extensive antimicrobial coverage, our patient deteriorated due to late suspicion of severe fungal pneumonia. Specimens confirmed disseminated spread of Blastomyces resulting in fulminant ARDS. This case demonstrates the importance of broad differential diagnoses in healthy individuals with unresolving symptoms. Fungal and atypical viral infections should be considered early. Our patient was likely exposed to B. dermatitidis while participating in an intense muddy obstacle course several months prior to onset of disease.
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DISCLOSURE: The following authors have nothing to disclose: Anjana Sathyamurthy, Thomas Hovenic, Vamsi Guntur
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