USE OF CORTICOSTEROIDS IN SEVERE PULMONARY BLASTOMYCOSIS IN A CONSTRUCTION WORKER IN NEW YORK STATE

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pulmonary blastomycosis, endemic to the midwestern, southcentral and southeastern regions of United States, is a rare occurrence with only a few cases reported in non-endemic areas. The mortality rate can be as high as 50 to 89% with significant pulmonary involvement. In non-endemic areas, such as New York, it is often overlooked as a potential pathogen. A few cases have been reported in New York along the St. Lawrence River. Here, we present a rare case of an immunocompetent patient with severe pulmonary blastomycosis without any significant travel history outside New York who required treatment with Amphotericin B and Methylprednisone. CASE PRESENTATION: 22 year-old male with history of cocaine and marijuana use presented to the hospital with 2 weeks of cough and pleuritic chest pain. He worked as a roofer without any personal protective equipment. On arrival, he was febrile (103˚ F) in mild respiratory distress with rales auscultated in the left upper lobe. CT thorax showed extensive consolidation of left upper lobe and lingula with left hilar adenopathy. He was HIV negative. Bronchial alveolar lavage (BAL) showed Aspergillus EIA was 0.90 units (normal < 0.5). Empiric IV Voriconazole was started initially and then switched to liposomal amphotericin B when patient was clinically deteriorating. Since his oxygen requirements were increasing with further deterioration of respiratory status, Methylprednisone 60mg IV every 6 hours was started and tapered to off after a 12 day course. Later, BAL fungal culture was found to be positive for Blastomyces Dermatitidis. He eventually showed improvement and was discharged home. DISCUSSION: Blastomycosis is rare with a yearly incidence rate of 1 to 2 cases per 100,000 population in states where it is reportable. This is an unusual case of Blastomycosis occurring without any travel or camping history, suggesting Marijuana from infected soil or a roofing occupation as a possible source. Treatment depends on disease severity. An azole is preferred for mild to moderate disease not involving the central nervous system. Amphotericin B is used for moderate to severe pulmonary infection or disseminated blastomycosis. Some immunocompetent patients may not require treatment, whereas all immunocompromised patients require treatment. No clear guidelines exist for the use of corticosteroids in fungal pneumonia. The use of steroids in case reports of ARDS from blastomycosis showed some improvement. In our case, corticosteroids proved to be of clinical benefit. CONCLUSIONS: This case urges clinicians to include blastomycosis on the differential even in non-endemic areas from unusual sources. Further research is needed regarding the use of corticosteroids in Blastomycosis. Reference #1: Bariola, J., and Keyur Vyas. “Pulmonary Blastomycosis.” Seminars in Respiratory and Critical Care Medicine, vol. 32, no. 06, 13 Dec. 2011, pp. 745–753., https://doi.org/10.1055/s-0031-1295722. Reference #2: Goldman, Mitchell, et al. “Fungal Pneumonias.” Clinics in Chest Medicine, vol. 20, no. 3, 1 Sept. 1999, pp. 507–519., https://doi.org/10.1016/s0272-5231(0570232-x). Reference #3: Permpalung, Nitipong, et al. “Pulmonary Blastomycosis: a New Endemic Area in New York State.” Mycoses, vol. 56, no. 5, 18 Mar. 2013, pp. 592–595., https://doi.org/10.1111/myc.12073. DISCLOSURES: No relevant relationships by Jagadish Akella, source=Web Response No relevant relationships by Artur Alaverdian, source=Web Response No relevant relationships by Ashlie Arthur, source=Web Response No relevant relationships by Javed Iqbal, source=Web Response No relevant relationships by Dolly Patel, source=Web Response No relevant relationships by Pranay Srivastava, source=Web Response