Case Presentation: A 71-year-old female presented to an emergency department with progressive weakness and dyspnea with dry cough for 2 weeks; she was afebrile but hypoxic, requiring 2 liters oxygen by nasal cannula. Physical examination was remarkable for diminished right lung sounds. Labs were unremarkable except for elevated C-reactive protein (194.6 mg/L). Chest x-ray revealed a dense consolidation in the right lung base with pleural effusion. CT with PE protocol showed a small right lower lobe pulmonary embolism, mass-like infiltrate, and central adenopathy. Pneumonia and malignancy were initially suspected. Moxifloxacin was started and later switched to ceftriaxone. The patient was started on enoxaparin, but this was discontinued due to bleeding complications. Therefore, she subsequently underwent IVC filter placement. Two right-sided thoracenteses were performed; pleural fluid analysis demonstrated exudative effusions. Bronchoscopy, bronchoalveolar lavage (BAL), and bronchial biopsy of the right upper lobe were performed. Cultures and cytology were negative for organisms and malignancy, respectively.
She continued to be hypoxic, now requiring 7-10L high-flow oxygen. She was transferred to the authors’ hospital 13 days after initial presentation. Upon arrival, patient was tachypneic with increased work of breathing. Due to impending respiratory failure, the patient was intubated. She developed septic shock complicated by ARDS requiring norepinephrine. Another bronchoscopy with BAL was performed. Analysis showed a red blood cell count of 4500/μL and a white blood cell count of 1,575/μL; 86% neutrophils, 1% lymphocytes, 6% eosinophils, and 7% monocytes/macrophages. Visualization of BAL fluid showed broad-based budding yeast, and blastomycosis was suspected. The patient was started on amphotericin B and steroids due to the severity of the inflammatory response. Cultures later confirmed Blastomyces dermatidis. She completed 2 weeks of amphotericin B during hospitalization and was discharged to a long term care facility on itraconazole 200mg twice daily for 6-12 months.

Discussion: This case illustrates the need for clinicians to maintain a high suspicion for fungal infections in patients with respiratory distress refractory to standard care. Although ARDS is a rare complication of blastomycosis, it has a high mortality rate. The standard treatment regimen alone is insufficient to treat blastomycosis complicated by ARDS. This case, along with several others, demonstrates successful management with adjuvant steroids. Nevertheless, there have been no conclusive studies indicating the effectiveness of an adjunctive agent in the treatment of blastomycosis associated ARDS.

Conclusions: Blastomycosis is a systemic fungal infection caused by Blastomyces gilchristii or Blastomyces dermatidis. Oftentimes, infection can mimic other diseases, resulting in delayed diagnosis and treatment and therefore worse outcomes. Rarely, it is complicated by acute respiratory distress syndrome (ARDS), which is associated with a high mortality rate and often requires adjunctive treatment. Here we report a rare case of an immunocompetent patient with blastomycosis complicated by ARDS. Similar cases should continue to be reported to increase clinicians’ awareness of this infection and to hasten diagnosis and develop more effective treatments.