BLAST IN THE VERTEBRAL BODY

Abstract

SESSION TITLE: Medical Student/Resident Lung Pathology 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bone is the third most frequent site of disease in patients with blastomycosis, and the vertebrae are among the bones affected most often. We describe the clinical features and treatment of a patient with vertebral blastomycosis. This case is very interesting because of its unusual presentation and symptoms. CASE PRESENTATION: A 25 year old male who lives in Wisconsin with no medical history presented to the emergency room (ER) with upper chest and back pain for past 6 months. He denies any travel history, no intravenous drug abuse, no sick contacts, no unintentional weight loss and no sexual contact in last 12 months. He does complaints of night sweats that began 2 weeks prior to his ER visit. Upon further questioning, the patient mentioned that he had some dry cough 6-8 months ago for which he was seen at the outside hospital. He was prescribed Azithromycin and discharged home. He did not follow up with his primary care doctor. Request was sent to obtain the records from the other hospital.CT angiogram was obtained during this hospitalization , it was negative for active pulmonary embolism but revealed posterior mediastinal mass in the superior mediastinum involving the posterior aspect of the thoracic spine, vertebral body with lytic ad sclerotic changes. MRI of cervical and thoracic spine showed large infiltrative enhancing lesion which extends from C7-T5,extensive osseous involvement, posterior mediastinal involvement with mass effect, foraminal obliteration and possible partial encasement of the vertebral arteries. This changes appeared to be of some sort of malignancy. To further evaluate the pathology cardiothoracic surgery was consulted. They recommended that esophageal ultrasound should be obtained to get the biopsy of the mass. The biopsy showed acute inflammatory debris with histiocytes and multi-nucleated giant cells including double refractile yeast forms with broad-based budding, Kinyoun stain negative for acid-fast bacilli and no evidence of malignant cells. After carefully reviewing the old images, it showed that he had a left middle lobe infiltrate which could have been an primary infection with Blastomycosis. The patient was discharged on long term Itraconazole. DISCUSSION: This case teaches us the importance of broad differential diagnoses in evaluating a patient. It is also very important to get detailed history and physical exam in evaluating the patient. Teamwork played a major role in this patients correct diagnosis and successful treatment. This case also gives us insight into how uncommon diseases present with uncommon manifestations. CONCLUSIONS: This case is of utmost clinical significance because it teaches us important aspect to approach a patient with unique presentation. It is also important to obtain detail history and also important to review images on your own to get the complete picture. Reference #1: Ralph ED, Plaxton WR, Sharpe MD. Treatment of severe pulmonary blastomycosis with oral itraconazole: case report. Reference #2: Saccente M, Abernathy RS, Pappas PG, Shah HR, Bradsher RW. Vertebral blastomycosis with paravertebral abscess: report of eight cases and review of the literature. Clin Infect Dis 1998;26:413–418 Reference #3: Sobel JD. Practice guidelines for the treatment of fungal infections. For the mycoses study group, Infectious Diseases Society of America. Clin Infect Dis 2000;30:652. DISCLOSURES: No relevant relationships by Vimalkumar Patel, source=Web Response