CHEST Guidelines-A-56-Year-Old-Man-With-Progressive-Subacute-Hypoxe

A-56-Year-Old-Man-With-Progressive-Subacute-Hypoxe

Pdf Summary

This case study details a 56-year-old man who experienced severe respiratory failure after working in an old farmhouse in Vermont. Initially treated with doxycycline for his symptoms of exhaustion and nonproductive cough, his condition worsened, leading to hospitalization and intubation. The clinical findings included diminished breath sounds and laboratory results showing leukocytosis and neutrophilia. Notably, broad-based budding yeasts were detected in the patient's bronchoalveolar lavage (BAL) test, leading to a diagnosis of pulmonary blastomycosis.<br /><br />Blastomycosis is an infection caused by Blastomyces fungi, predominantly found in certain North American regions but increasingly reported in New England states such as Vermont. The infection can manifest as severe pulmonary involvement and progress to acute respiratory distress syndrome (ARDS), which can be fatal. Despite comprehensive ventilatory support, including ECMO (extracorporeal membrane oxygenation), the patient's hypoxemic respiratory failure required further interventions, eventually leading to recovery and discharge with itraconazole therapy.<br /><br />The discussion highlights the complexities of managing ARDS due to Blastomyces, considering factors such as the choice of antifungal treatment and ECMO's potential role in management. While liposomal amphotericin is preferred due to less nephrotoxicity, it poses challenges in ECMO settings, leading to the use of amphotericin deoxycholate with adjusted dosing.<br /><br />Clinical pearls emphasize the necessity of high suspicion for blastomycosis in endemic areas, ECMO's feasibility in ARDS cases resulting from this infection, and considerations for drug interactions with ECMO. The case advocates for recognizing the potential lifesaving impact of ECMO, despite limited data, in managing severe cases of blastomycosis, suggesting individualized treatment strategies.

Keywords

Blastomycosis

ARDS

ECMO

pulmonary blastomycosis

itraconazole therapy

Vermont

respiratory failure

bronchoalveolar lavage

antifungal treatment

liposomal amphotericin