INFECTIOUS DISEASE CONSULT- MYSTERY DIAGNOSIS

Document Type

Conference Proceeding

Publication Date

7-17-2025

Publication Title

J Gen Intern Med

Abstract

CASE: A 57 year old male with alcoholic cirrhosis and psoriasis presented with 3 weeks of erythematous, tender, purple plaques on bilateral upper and lower extremities. He was intubated and sedated due to respiratory distress. The patient’s wife shared that the patient had experienced a 14-pound weight loss and had a nonproductive cough over the past 3 months. She said he had no recent sick contacts, fevers or chills, but did endorse travel to the Upper Peninsula of Michigan a few weeks prior to symptoms. On presentation, the patient was afebrile, tachycardic, normotensive, and intubated on mechanical ventilation with an FiO2 of 100% and PEEP of 18. Physical exam revealed coarse breath sounds in bilateral lower lung fields and purple crusted plaques on bilateral upper and lower extremities with no drainage, warmth, or edema. Due to the patient’s medical history, recent travel, and current symptoms, our differential included fungal pneumonia, tuberculosis, invasive aspergillosis, histoplasmosis, blastomycosis, vasculitis, and noninfectious lung disease. Labs showed leukocytosis (11.4 x 109 cells/L) but were negative for urinalysis, blood and respiratory cultures, immunoglobulins, C3, C4, ANA, ANCA, anti-GBM, hepatitis screening, HIV, RPR, Cryptococcal antigen, and Fungitell test. Chest x-ray showed diffuse parenchymal airspace abnormalities and CT chest revealed ground-glass heterogeneity throughout the lungs. A high suspicion for disseminated blastomycosis was maintained due to the patient’s immunocompromised state, geographic exposure, pulmonary findings, and characteristic skin lesions. Infectious Disease was consulted and IV amphotericin B was started. Unfortunately, the patient coded and died 2 days after starting treatment. Urine antigen and skin biopsy later confirmed Blastomyces dermatitidis. IMPACT/DISCUSSION: Our case highlights the importance of a detailed social history, specifically regarding microbial exposure from travel. This case reinforces the significance of considering disseminated fungal infection in immunocompromised patients. Finally, it depicts the limitation of relying on Fungitell, which has low sensitivity for the yeast form of Blastomyces, particularly in ICU patients. Fungitell’s sensitivity can range from 27% to 100% depending on the assay used, positive cutoff criteria, and patient population. When blastomycosis is suspected, alternative diagnostics including urine antigen testing, skin biopsy histopathology, and/or KOH stain and fungal culture from respiratory samples should be considered. CONCLUSION: This case underlines the importance of obtaining a comprehensive social history, maintaining suspicion for disseminated fungal infection in immunocompromised patients with respiratory illness, and studying the sensitivity of diagnostic tests.

Volume

40

First Page

S241

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