Case Presentation: The patient is a 29-year-old female twenty weeks pregnant that presents after a positive tissue culture for blastomycosis. The patient reported symptoms that started with a few days of upper right back pain and shortness of breath, similar complaints to pneumonia symptoms the patient had in the past. The patient was prescribed azithromycin by her primary care provider (PCP) for suspected pneumonia, but her shortness of breath and pain persisted. A few weeks afterwards, the patient presented to the ED with sharp chest pain and hemoptysis. CT imaging showed “interval development of suspicious tissue along the paraspinal region from T1-T6, extending across the mediastinum into the central left lung.” There were also associated erosions along the left-side of the T3 and T4 vertebral bodies, suspicious of malignancy. Due to transplacental transmission of contrast, a PET scan was deferred in favor of CT biopsy that revealed tissue consistent with blastomycosis and was notified to come back to the emergency department. When seen in the ED, the patient endorsed worsening dyspnea on exertion, pain upon inspiration, poor p.o. intake, with a weight loss of ten pounds in the last month. Her family lives on an Indian reservation in northern Wisconsin and hikes in the woods at their house frequently. Patient mentioned a neighbor who was recently diagnosed with blastomycosis ten minutes away from her parent’s house. Tissue biopsy was corroborated by high urine blastomycosis antigen and sputum fungal culture. Amphotericin B was initiated due to suspected disseminated disease because of the upper right back pain and CT imaging. MRI revealed no radiographic evidence of CNS involvement, allowing a decrease in Amphotericin B dosage. Upon discharge, a PICC line was placed for daily infusions of Amphotericin B for 6-12 months with the plan to transition to oral azoles after the patient finishes breastfeeding as there is a risk of azole transmission through breast milk.
Discussion: Blastomycosis in pregnancy is exceedingly rare and has a high incidence in rural communities such as Indian reservations and in the Great Lake regions of the United States. Pregnancy is an immunosuppressive state which can alter susceptibility to and severity of infectious diseases. In this case, the immunosuppressive state of pregnancy, along with living in an endemic region, led to the acquisition of blastomycosis. Careful synthesis of the treatment plan should be discussed as there is a risk of transplacental spread. Where oral azoles are typically first line, azole use in pregnancy is contraindicated due to teratogenic effects in the form of facial, axial skeleton, and limb defects. Amphotericin B should be used in pregnancy, but careful monitoring of labs such as magnesium, potassium, kidney function, and liver function is imperative to prevent end-organ damage.
Conclusions: Epidemiological studies have shown that certain populations, including Native Americans, have a higher prevalence of blastomycosis. Blastomycosis primarily affects the lungs, causing pneumonia-like symptoms, and if not contained by the immune system, can spread to other organs. Blastomycosis during pregnancy is exceedingly rare, with only a few reported cases over the past century. Transplacental spread can occur and lead to fetal demise if not appropriately treated. Azoles such as itraconazole, which are the first-line treatment for blastomycosis, are contraindicated in pregnancy due to its teratogenicity; thus, in pregnant patients, amphotericin B is preferred.