Case Presentation:
A 44-year-old Hmong female presented to the Emergency Department with cough and shortness of breath. The cough started three weeks prior to presentation and produced yellow-green sputum. She also experienced fevers and chest pain during this time. One week prior, her PCP recommended a cough medicine with no improvement of symptoms. She denied sore throat, congestion, hemoptysis, headaches, rash, sick contacts, and recent travel.
Vital signs were significant for tachycardia to the 120s and oxygen saturations in the low 90s. Rhonchi were heard throughout all lung fields. Chest X-ray showed bilateral perihilar and basilar opacities greater on the left side. She was started on ceftriaxone and azithromycin in the ED and vancomycin was added the next day on the hospital floor. Despite antibiotics, she continued to have fevers, cough, and shortness of breath. Per Infectious Disease consult, a CT scan and cultures were obtained. Infectious work up including QuantiFERON-TB and COVID-19 testing were negative.
Itraconazole was started three days after presentation due to a presumed Blastomycosis diagnosis when sputum cultures revealed broad based budding yeast. Chest CT revealed diffuse scattered consolidative and nodular densities with complete consolidation of the left lower lobe and early central cavitary changes. Urine later confirmed Blastomyces antigens. Amphotericin B was added one day after starting Itraconazole for worsening respiratory status and persistent tachycardia. Despite treatment, Pulmonology recommended transfer to the ICU six days after admission due to impending respiratory failure.
Discussion:
Blastomycosis is a rare but life-threatening fungal infection. Diagnosis and subsequent treatment are often delayed since it presents with non-specific symptoms and rarely occurs in immunocompetent hosts. Presenting symptoms include cough, fever, sputum production, hemoptysis, shortness of breath, weight loss, night sweats, and chills. It is frequently misdiagnosed as community acquired pneumonia, viral pneumonia, or Tuberculosis leading to delayed treatment and worse outcomes.
Here we report the identification and treatment of blastomycosis in an immunocompetent Hmong patient who presented with non-specific pulmonary symptoms. People of Hmong ancestry are at increased risk of Blastomycosis. Large populations of Hmong have settled in Wisconsin which is an area endemic to Blastomycosis 1. In addition, Hmong are more susceptible to this infection due to genetic differences in immune response to Blastomyces dermatitidis 2. This case highlights the importance of considering both ethnicity and geographic region when developing the differential.
Conclusions: In Midwestern states with a high Hmong population, it is important to keep Blastomycosis high on the differential. If a Hmong patient presents with non-specific pulmonary symptoms, sputum or tissue samples should be collected immediately for testing so as not to delay treatment. Identification of broad budding yeast in these specimens provide justification for starting anti-fungal therapy.