Indiana University, Indianapolis, IN
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Fellow Case Report Poster - Chest Infections I
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Adult Respiratory Distress Syndrome (ARDS) often presents with high mortality as a late manifestation of the Blastomycosis. An initial high index of suspicion must be used to diagnose this disease in at risk populations even when chest x-ray is clear. Yeast may be isolated in body fluid or tissue specimen of other extrapulmonary organs involved.
CASE PRESENTATION: A 44-year-old Hispanic male with uncontrolled diabetes mellitus presented for knee pain and cough. Patient had been seen 3 days prior with a normal chest radiograph and was given levofloxacin. After 24 hours of treatment with inpatient antibiotics, he transferred to the ICU for oxygen requirements. Physical exam was remarkable for fever, tachycardia, and hypoxemia. His lungs sounded coarse, and there was a left knee effusion. Plain chest radiograph showed developing diffuse miliary opacities. A knee arthrocentesis aspirated white synovial fluid that stained positive for Blastomyces dermatitidies. Patient was intubated in the ICU for ARDS. Commuted tomography revealed nodular opacities in a military distribution. Amphotericin B lipid complex was initiated at 5mg/kg/day and methylprednisolone 0.5 mg/kg daily was added for ARDS.
DISCUSSION: Despite a normal chest radiograph days prior, our patient developed ARDS, a rare complication of blastomycosis reported to have up to 89% mortality. Prompt diagnosis from the knee effusion allowed for rapid initiation of treatment with amphotericin B. While there is still paucity of evidence for the true benefit of corticosteroids to ARDS in blastomycosis, corticosteroids was added for anti-inflammatory effects. Our patient responded well to treatments and was able to be discharged after 2 weeks in the hospital on no oxygen.
CONCLUSIONS: The key to early diagnosis of blastomycosis is through direct visualization of yeast forms in cytologic or pathologic specimen. Blastomycosis can be examined directly via potassium hydroxide wet mount, cytology, or histopathology of the tissue specimens. With our patient, the diagnosis of blastomycosis was first made by direct visualization of yeast with calcaflour stain on the synovial aspiration of knee.
Reference #1: Azar MM, Assi R et al. Blastomycosis in Indiana: Clinical and Epidemiologic Patterns of Disease Gleaned from a Multicenter Retrospective StudyChest. 148(5):1276-1284, November 2015.
Reference #2: Lahm T, Neese S, Thornburg AT, Ober MD, Sarosi GA, Hage CA. Corticosteroids for blastomycosis-induced ARDS: a report of two patients and review of the literature. Chest 2008;133:1478-1480.
DISCLOSURE: The following authors have nothing to disclose: Min Qi, William Carlos, Babar Khan
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