BUT WHAT ABOUT THE RASH?
Chest
; 162(4):A421, 2022.
Article
in English
| EMBASE | ID: covidwho-2060592
ABSTRACT
SESSION TITLE Severe and Unusual Blastomycosis Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/18/2022 1225 pm - 0125 pm INTRODUCTION:
This is a case of a patient 74-year-old immunosuppressed woman presenting with a one-week history of skin lesions. CASE PRESENTATION A 74-year-old woman with Crohn's disease (on weekly adalimumab);pulmonary hypertension (RVSP 76 mmHg);OHS/OSA, on home BPAP 17/7 cmH2O;and morbid obesity presented with a one-week history of skin lesions. She was seen by her primary care physician two days prior with skin lesions, shortness of breath, and decreased vision. She was hypoxic during the visit and given doxycycline for empiric treatment of pneumonia. She denied recent travel or exposure to animals. On admission, she was afebrile (36.9C) and saturating 98% on 2 L nasal cannula. She appeared chronically ill with mouth ulcers and an eroded nodule with overlying hemorrhagic crusting and peripheral pustular area above her right eyebrow (figure 1). Throughout her skin, she had multiple erythematous papules, some with overlying vesicles/pustules. Labs were significant for a leukocytosis of 19.3 with left shift, lactate of 3.5, serum creatinine of 1.9 (likely higher than patient's previous baseline of 1.7 with previous history of recurrent AKIs on CKD), elevated inflammatory markers, and normal ALT/AST. Influenza and COVID were negative. A CT chest showed consolidations and numerous pulmonary nodules highly suspicious for an infectious or inflammatory process (figure 2). She was treated empirically with vancomycin, piperacillin-tazobactam, valacyclovir, and amphotericin B, the latter given the concern of blastomycosis. During her hospitalization, she had further respiratory failure requiring intubation and multiorgan failure. Disseminated blastomycosis was confirmed via a skin biopsy which demonstrated pyogranulomatous inflammation with numerous broad-based budding yeasts (figure 3) and supported with a bronchoalveolar lavage (BAL) culture growing the same. Given her continued decline, her medical decision maker decided to transition the patient to hospice care.DISCUSSION:
Blastomycosis is a systemic pyogranulomatous infection that is caused from the inhalation of the conidia form of the dimorphic fungus. It can manifest as asymptomatic infection, acute or chronic pneumonia, or extrapulmonary disease. BAL yields a positive diagnosis in 92% of patients and definitive diagnosis requires growth of the organism from a clinical specimen. Without appropriate treatment of amphotericin B or one of the azole antifungals, the disease had a 90% mortality rate.CONCLUSIONS:
Prompt recognition of multiorgan failure secondary to blastomycosis is important for early treatment and improved survival in immunocompromised patients Reference #1 1)Chapman, S W et al. "Endemic blastomycosis in Mississippi epidemiological and clinical studies.” Seminars in respiratory infections vol. 12,3 (1997) 219-28. Reference #2 2)Saccente, Michael, and Gail L Woods. "Clinical and laboratory update on blastomycosis.” Clinical microbiology reviews vol. 23,2 (2010) 367-81. doi10.1128/CMR.00056-09 Reference #3 3)Chapman, Stanley W et al. "Clinical practice guidelines for the management of blastomycosis 2008 update by the Infectious Diseases Society of America.” Clinical infectious diseases an official publication of the Infectious Diseases Society of America vol. 46,12 (2008) 1801-12. doi10.1086/588300 DISCLOSURES No relevant relationships by Jennifer Duke No relevant relationships by Ashley Egan
adalimumab; amphotericin B; antifungal agent; doxycycline; lactic acid; piperacillin plus tazobactam; valaciclovir; vancomycin; aged; aspartate aminotransferase level; asymptomatic infection; bilevel positive airway pressure; blastomycosis; budding yeast; case report; chronic patient; clinical article; communicable disease; conference abstract; conidium; coronavirus disease 2019; creatinine blood level; Crohn disease; drug combination; drug therapy; dyspnea; eyebrow; female; general practitioner; hospice care; hospitalization; human; human tissue; immunocompromised patient; infectious inflammation; inflammation; influenza; inhalation; intubation; leukocytosis; lobar pneumonia; low vision; lung lavage; lung nodule; microbiology; Mississippi; morbid obesity; mortality rate; mouth ulcer; multiple organ failure; nasal cannula; nonhuman; papule; pneumonia; practice guideline; pulmonary hypertension; pustule; respiratory failure; respiratory tract infection; skin biopsy; skin defect; survival; thorax; travel
Full text:
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Collection:
Databases of international organizations
Database:
EMBASE
Language:
English
Journal:
Chest
Year:
2022
Document Type:
Article
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