CHEST Guidelines-A 66 Year Old Woman With Fever, Cough, and a Tongu...

A 66 Year Old Woman With Fever, Cough, and a Tongu...

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The medical case presented involves a 66-year-old woman who developed acute symptoms, including fever, cough, chest pain, and a tongue lesion. Her medical history includes Coombs-positive autoimmune hemolytic anemia treated with prednisone, VTE requiring anticoagulation, and steroid-induced diabetes mellitus. She has a background of TB treatment, exposure to cows in Nepal, and recent travel to Nepal and Syracuse, NY.<br /><br />Upon examination, her vital signs were stable, but she displayed decreased breath sounds and a tongue ulcer. Laboratory tests showed anemia and electrolyte imbalances. Imaging revealed a dense opacity in the right lung, leading to the diagnosis of pneumonia, initially treated with antibiotics and continued prednisone. However, her condition, including anemia and right-sided lung opacification, worsened.<br /><br />A CT scan revealed multilobar lung consolidation, and biopsies from the tongue and bronchoscopy indicated granulomatous inflammation with microorganisms. Cultures confirmed disseminated blastomycosis, particularly challenging due to her compromised immunity from steroid use. Blastomycosis, caused by Blastomyces dermatitidis, is primarily a North American soil-borne fungal infection acquired through inhalation. Diagnosis can be elusive, often mimicking bacterial pneumonia because of its protean manifestations.<br /><br />The patient was treated with itraconazole, an antifungal, and eventually improved without receiving AmB, the traditional treatment for severe cases. Her condition highlights the importance of considering endemic fungal infections in immunosuppressed individuals, even in non-endemic areas, and underscores the critical role of biopsy and culture in diagnosing elusive pathogens. Despite potential for spontaneous resolution, standard practice dictates antifungal treatment to prevent high mortality seen historically.

Keywords

blastomycosis

immunosuppression

fungal infection

pneumonia

itraconazole

granulomatous inflammation

steroid-induced diabetes

lung consolidation

Coombs-positive anemia

endemic infections