A FLORIST'S OCCUPATIONAL EXPOSURE

Abstract

SESSION TITLE: Chest Infections: Find the Fungus SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Pulmonary infections have been reported in up to 79% of patients with blastomycosis. Often known as a “great pretender” given the large variability in presentation, pulmonary blastomycosis is a diagnostic dilemma even in endemic areas. Here we report a case of acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO) in an immunosuppressed patient working as a florist with no travel history to an endemic area. CASE PRESENTATION: 54 year old male from central New York with history of autoimmune hepatitis on azathioprine and corticosteroids, presented with worsening cough, dyspnea and fever. He denied any sick contacts or travel history and worked as a florist. He failed outpatient pneumonia treatment with azithromycin and then doxycycline. His symptoms continued to progress, and was admitted to the ICU with acute hypoxic respiratory failure, requiring mechanical ventilation. Chest x-ray revealed patchy bilateral airspace disease and he was started on broad spectrum antibiotics and voriconazole. CT Chest showed extensive consolidation in right lower and middle lobe, left lower lobe and lingula, with mediastinal lymphadenopathy. He progressed to ARDS with worsening respiratory status despite maximal ventilator support and paralytics, and was emergently placed on ECMO. A bronchoscopy revealed thick copious mucous plugs and both bronchial washings and lavage were sent for culture. Initial blood cultures and bronchoscopy cultures returned negative for pathogens, however 10 days after bronchoscopy, lavage culture grew mold, later identified as Blastomyces dermatiditis. He was started on amphotericin B, and later changed to itraconazole. After initiation of an anti-fungal the patient clinically improved and was decannulated from ECMO, with eventual discharge to rehab. DISCUSSION: The diagnosis of pulmonary blastomycosis can range from an asymptomatic infection to pneumonia or to ARDS. The lung is often the primary inoculation site after exposure to disrupted soil. However this diagnosis requires a high degree of clinical suspicion even in endemic sites or those with a travel history to such areas. This case highlights a diagnostic dilemma in an immunocompromised patient, who presented with fulminant respiratory failure due to blastomycosis, with no travel history to an endemic area. Here we see a case of an occupational exposure to soil given his profession as a florist as his likely source, with his immunocompromised state leading to devastating disease. This emphasizes the importance of identifying occupational exposures especially when combined with those who are immunosuppressed, as early diagnosis and treatment will be lifesaving. CONCLUSIONS: ARDS due to pulmonary blastomycosis carries a high mortality rate highlighting the vital importance of early diagnosis and treatment. Reference #1: McBride JA, Gauthier GM, Klein BS. Clinical Manifestations and Treatment of Blastomycosis. Clin Chest Med. 2017;38(3):435-449. Reference #2: Moore NM, Proia LA. Severe acute respiratory distress syndrome in a liver transplant patient. Med Mycol Case Rep. 2018;21:1-3. Published 2018 Mar 6. https://doi.org/10.1016/j.mmcr.2018.03.005 Reference #3: Salzer H, J, F, Burchard G, Cornely O, A, Lange C, Rolling T, Schmiedel S, Libman M, Capone D, Le T, Dalcolmo M, P, Heyckendorf J: Diagnosis and Management of Systemic Endemic Mycoses Causing Pulmonary Disease. Respiration 2018;96:283-301. https://doi.org/10.1159/000489501 DISCLOSURES: No relevant relationships by Hassan Al Khalisy, source=Web Response No relevant relationships by Ioana Amzuta, source=Web Response No relevant relationships by Ritu Modi, source=Web Response