SEVERE PULMONARY BLASTOMYCOSIS IN A PATIENT WITH A COVID-19-POSITIVE TEST: A DANGEROUS ANCHORING BIAS

ABSTRACT

SESSION TITLE Severe and Unusual Blastomycosis Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/18/2022 1225 pm - 0125 pm INTRODUCTION: Severe pulmonary blastomycosis (PB) usually affects immunocompromised patients, with very high mortality rate of up to 40%. PB can mimic pneumonia caused by other organisms (1), which can delay diagnosis and treatment initiation. We present a case of severe PB that was initially thought to be COVID-19 pneumonia, to our knowledge this is 2nd case of concomitant PB and COVID-19 infection in literature. (2) CASE PRESENTATION Patient is 52 year old female with past medical history of atrial fibrillation, asthma, bariatric surgery, that presents with shortness of breath for 2 weeks. Despite receiving only 1 dose of COVID-19 vaccine (Moderna) 5 months ago, patient tested positive for COVID-19 on PCR test at the urgent care 4 days prior. Her symptoms progressed despite initial outpatient treatment with steroids and antibiotics. Initial emergency department chest computed tomography (CT) revealed dense bilateral consolidations, with hypoxic respiratory failure, patient was admitted for treatment of presumed COVID-19 pneumonia, and guideline directed treatment was initiated. Despite maximal medical management, that included steroids, broad spectrum antibiotics, remedisivir, patient failed to improve, with repeat CT chest revealing worsening consolidations. Bronchoscopy was performed 12 days into the admission revealed thick white secretions, with cultures growing blastomyces dermatitidis. At this point patient development of septic shock with multiorgan failure. Patient was subsequently intubated, and due to significant renal failure, initiated on hemodialysis (HD). Anti-fungal treatment was initiated with amphotericin B, and transitioned to itraconazole afterwards. Patient required several HD sessions, after which her renal function fully recovered. Patient was successfully extubated 7 days later, but required additional 22 days of medical care and physical therapy before being ready for discharge to rehabilitation facility. On the outpatient follow up 6 weeks after discharge, patient continues to slowly recover. Repeat CT chest still with significant bilateral consolidations. Patient will require at least 12 months of itraconazole therapy. DISCUSSION: PB can mimic bacterial and viral pneumonia symptoms. (1) In the widespread COVID-19 pandemic, clinicians can be misled by COVID-19 positive test in patient with bilateral pneumonia, and initiate guideline directed therapy. Immunosuppression agents can lead to adverse outcomes in patients with underlying PB. Questionable is the significance of COVID positive PCR test in semi-vaccinated individual. Potentially even mild COVID-19 infection could predispose patient for PB. Early diagnosis of PB is important, as delay in treatment and medical immunosuppression can lead to worse outcomes. CONCLUSIONS: PB should be suspected even in patients presenting with positive COVID-19 PCR test. Guideline directed therapy for COVID-19 can worsen underlying PB. Reference #1 https//www.cdc.gov/fungal/covid-fungal.html Reference #2 https//www.ncbi.nlm.nih.gov/pmc/articles/PMC8503152/ DISCLOSURES No relevant relationships by Dovile Baniulis No relevant relationships by Dovile Cerkauskaite No relevant relationships by Igor Dumic No relevant relationships by Momcilo Durdevic No relevant relationships by Dragana Durdevic No relevant relationships by Ashutossh Naaraayan No relevant relationships by Ankita Subedi