Case Presentation: 21F PMH asthma initially presented to the ED with low grade fevers and URI symptoms. She was 29 weeks pregnant at the time. In the ED she was worked up and found to be Influenza positive with a consolidation suspicious for CAP. Pt initially admitted to the ICU for presumed sepsis secondary to CAP, where she was started on ceftriaxone and azithromycin. Despite this course of treatment, she remained tachypneic and tachycardic with WBC near 40,000 for several days. Additional testing for possible fungal etiologies, as well as broadening coverage to vancomycin, zosyn, and azithromycin were performed under ID’s guidance. A CT-Chest was obtained the next day and showed loculated pleural effusion with mediastinal lymphadenopathy. The next day, Histoplasmosis and blastomycosis antigens returned positive. CT-Chest was also noted to show an enlarged thyroid with nodules. Biopsy of said nodule confirmed disseminated blastomycosis infection. Pt was immediately started on amphotericin B and her symptoms and labs improved dramatically. Due to the gravity of her illness and concern for long term use of amphotericin B it was recommended that she be induced for preterm delivery of her baby. The consulting OB/Gyn made the decision for induction at 32 weeks gestation. The patient was transferred to the women’s hospital where she was induced and had an uncomplicated delivery. She received amphotericin B for another 2 weeks and was transitioned over to Itraconazole for an additional 1 yr.
Discussion: Due to pregnancy, azoles could not be used initially. The fact that she had moderate to severe infection was an indication to begin amphotericin B over azoles, at least initially (3,4). After dramatic improvement over the first few days of treatment with amp B, there was concern for long term complications of ampho B use. Decision was made to induce labor and the delivery was uncomplicated. Post delivery the pt was switched to an oral azole. Patient was advised she would be on this medication for 12 months and could not breastfeed. The starting regimen consisted of itraconazole 200 mg three times daily for three days, then 200 mg twice daily (3). Although vertical transmission is possible, the neonate was negative for blastomycosis infection. The causative route has been theorized as intrauterine transmission, ingestion of maternal secretions, and vaginal infection (6).
Conclusions: In conclusion blastomycosis, especially when disseminated, has high mortality. Severe disease can be as high as 50% (7,8). The importance of early diagnosis is key. Thorough history taking for travel, sick contacts, and work environment are critical pieces of information providers should look to obtain. In an otherwise healthy female with severe respiratory symptoms and extremely elevated WBCs w/out improvement on empiric therapy should warrant a thorough workup. When working up fungal etiology remember cross reactivity between labs is likely. Results will not always match your suspicion. And when in doubt biopsy is key. In pregnancy, early diagnosis can prevent vertical transmission. We suggest considering early induction of labor in a pregnant female to reduce chances of spread as well as to avoid the toxicity of antifungals to not only the baby but the mother as well.