CHEST Guidelines-A-45-Year-Old-Woman-With-3-Weeks-of-Cough-and-Nigh

A-45-Year-Old-Woman-With-3-Weeks-of-Cough-and-Nigh

Pdf Summary

A 45-year-old woman with a history of renal transplantation presented with a 3-week history of low-grade fever, night sweats, dry cough, and increased fatigue. She had no notable medical history of tuberculosis or significant medication changes. After a recent move to Baton Rouge, Louisiana, she started experiencing symptoms. Physical examination showed elevated temperature but was otherwise normal, and diagnostic tests revealed only mild anemia and low sodium levels.<br /><br />The patient's chest radiograph and CT scan showed diffuse, bilateral tiny nodules in a miliary pattern, raising suspicion for tuberculosis, especially given her immunosuppressed state from medications such as tacrolimus, mycophenolate, and prednisone. However, tests for TB and other infections, including various viruses, returned negative. Despite treatment for suspected TB, her condition deteriorated, necessitating increased supplemental oxygen.<br /><br />Further investigation via bronchoscopy identified Blastomyces dermatitidis, a dimorphic fungus endemic to certain parts of North America, as the cause of her condition, now diagnosed as pulmonary blastomycosis with a miliary pattern. This is a rare presentation, particularly in immunocompromised patients, similar to those with HIV.<br /><br />This case emphasizes that detection of Blastomyces dermatitidis often requires culture or tissue biopsy, as serology testing is unreliable. Treatment for mild to moderate blastomycosis involves itraconazole, whereas moderate to severe cases, particularly in immunocompromised patients, require amphotericin B. Unfortunately, despite antifungal therapy initiation, the patient's condition progressed to severe acute respiratory distress syndrome (ARDS), and she succumbed to multiorgan failure. This case highlights the critical need for considering pulmonary blastomycosis in patients in endemic areas and the challenge in managing severe cases amidst immunosuppression.

Keywords

renal transplantation

immunosuppression

pulmonary blastomycosis

Blastomyces dermatitidis

miliary pattern

Baton Rouge

antifungal therapy

acute respiratory distress syndrome

endemic areas

dimorphic fungus