BLAST THE STEROIDS

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Acute Respiratory Distress Syndrome (ARDS) develops in CASE PRESENTATION: A 54-year-old florist from central New York, with a medical history of autoimmune hepatitis on immunosuppressive therapy with azathioprine and prednisone, presented with complaints of cough, shortness of breath and fever for one month after recently getting azithromycin and doxycycline without improvement as an outpatient. On exam, he was found to be in distributive shock with pneumonia as suspected source and required broad spectrum antibiotics and vasopressors. He failed conservative management and reuired mechanical ventilation and escalation to maximum vent settings. A decision was made to start veno venous Extra Corporeal Membrane Oxygenation (ECMO) for ARDS a day later. Patient was on broad antibiotics for empiric coverage of possible methicillin resistant Staph Aureus, atypicals and pseudomonal coverage, and voriconazole for fungal coverage. Bronchoscopy stains returned positive for mold and he was switched to Isavuconazole for invasive fungal infection. At last, bronchial washing cultures were positive for blastomycosis and he switched to amphotericin B. The dilemma at this point was the need for high dose steroids but due to the paucity of evidence on either side, this was not pursued. Over the following days, clinical and radiographic improvement allowed for weaning and decannulation off of ECMO. He later underwent tracheostomy but continued to improve with regards to deconditioning and was discharged to a rehab along with a prolonged course of oral itraconazole. DISCUSSION: High dose corticosteroids have been used in several fungal infections and have proven benefit in HIV infection with severe Pneumocystis jiroveci pneumonia (2) and with severe pulmonary infections with Histoplasma capsulatum (3). No clear-cut evidence is found in ARDS caused by Blastomyces however. We refrained from using high dose steroids in conjunction with antifungal therapy given the immunocompromised state of the patient and no large body of evidence showing benefit with use. CONCLUSIONS: There is no conclusive evidence for or against the use of high dose corticosteroids in the management of ARDS secondary to pulmonary blastomycosis in conjuction with antifungals. This case highlights that good outcomes can be achieved without the combination. More studies are required on this going forward. Reference #1: 1. Meyer KC, McManus EJ, Maki DG. Overwhelming pulmonary blastomycosis associated with the adult respiratory distress syndrome. Reference #2: 2. Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in the acquired immunodeficiency syndrome. The National Institutes of Health-University of California Expert Panel for Corticosteroids as Adjunctive Therapy for Pneumocystis Pneumonia N Engl J Med, 323 (1990), pp. 1500-1504 Reference #3: 3. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis, 45 (2007), pp. 807-825 DISCLOSURES: No relevant relationships by Hassan Al Khalisy, source=Web Response No relevant relationships by Pranita Ghimire, source=Web Response No relevant relationships by Subrat Khanal, source=Web Response