Previously healthy male in early 30s presents with progressive SOB with hemoptysis and low back pain over a period of months, acutely worse in the past few days. Hypoxic in the 60s on EMS arrival.

Initial Vitals:

SpO2 87% on 15L nonrebreather

HR 137

RR 40

BP 124/85

T 36˚C

ED Evalaution

Had been admitted recently for necrotizing PNA and treated with multiple courses of broad-spectrum antibiotics and steroids with little relief. Physical exam was remarkable for moderate respiratory distress with prolonged expiratory phase and disseminated lesions of the skin described as erythematous with a central clearing and raised borders measuring 1cm in various stages of healing.

Labs show an elevated alkaline phosphatase at 229, leukocytosis to 23000 with 29% bands, thrombocytosis to 532 and an elevated ANC at 21 with normal morphology. ESR >130, CRP 314 with elevated procalcitonin (2), and lactate (3). Negative covid and flu.

ED Course

CT Imaging showing diffuse GGOs with mediastinal lymphadenopathy and lytic lesions to ribs, spine and pelvis. Recent outpatient testing shows Negative AFB and Quantiferon, HIV, Hepatitis panel, ANCA panel, Sjogren’s Ab, and ANA.

Pt placed on BiPAP and taken to ICU where condition worsens, he is intubated and ultimately placed on V-V ECMO.

Biopsy of the above lesion grew filamentous fungus with broad based budding yeast which was confirmed by PCR as Blastomyces dermatitidis.

Disseminated Blastomycosis!

Next Steps: Treatment

Thermally dimorphic fungus spread through inhaled spores
Can mimic other diagnoses and often diagnosed late stage resulting in high mortality
Often lung, skin, and bony involvement
Diagnosis via histology and culture
Treatment itraconazole (mild to moderate disease), lipid amphotericin (moderate to severe)

Despite treatment with lipid amphotericin, due to the serious involvement of multiple organ systems the patient succumbed to their illness soon after.