Fatal blastomycosis after exogenous immunosuppression
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Published in the Journal of American Academy of Dermatology, the authors describe a fatal case of disseminated blastomycosis in a young man with rapid progression to multiorgan failure after exposure to corticosteroids.

A 31-year-old man presented with a persistent productive cough, fever, and dyspnea, worsening over 3 weeks. He had been on medical leave from his work as a horticulturalist for 4 years before his presentation because of polyarthralgia but had never received a specific diagnosis. Four weeks before presentation, a diagnosis of inflammatory arthritis of his right knee was made by a rheumatologist, and a tapering regimen of prednisone was prescribed, starting at 50 mg/d.

One month after starting prednisone, he presented to his regional hospital and rapidly progressed to hypoxemic respiratory failure requiring positive pressure ventilation. A computed tomography scan of the chest revealed innumerable diffuse small nodules at the end-bronchovascular bundles, with early cavitation of some lesions. His respiratory status continued to deteriorate despite empiric imipenem, vancomycin, azithromycin, and caspofungin.

A bronchoalveolar lavage was performed and yielded numerous large, broad-based budding yeast cells seen by direct calcofluor white staining. Culture of the bronchoalveolar lavage specimen confirmed B. dermatitidis.

Physical examination found a 1- × 2.7-cm well-demarcated plaque with a hemorrhagic crust and an erythematous border on his left forehead. A shave biopsy found an ulcerated specimen of skin with underlying loose granulomatous inflammation with frequent large round budding yeastlike organisms, also supporting the diagnosis of blastomycosis with dissemination to the skin. Culture of the lesion isolated B dermatitidis.

The patient could not be adequately oxygenated despite maximal ventilator support, and venovenous extracorporeal membrane oxygenation (ECMO) was initiated on day 3 after transfer. Despite maximal support, the patient had refractory multiorgan failure, and ECMO was withdrawn after 28 days according to family wishes.

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