ARDS With Fluctuating Skin Lesions

Abstract

INTRODUCTION: Blastomycosis is unique since it usually affects healthy, non-immunocompromised individuals. Lung involvement is the most frequent clinical manifestation; however, extrapulmonary manifestations involving skin (most common), bone, genitourinary tract and central nervous system are also described. Clinical presentation can vary from mild self limiting pulmonary infection to fulminant pneumonia and rarely, ARDS. CASE PRESENTATION: A 63 year old caucasian nonsmoker male farmer presented with dyspnea on exertion, dry cough, weight loss, skin ulcers and low grade fever for 3 months. He noted painful skin ulcers over his elbows and ankles that kept enlarging and increasing in number. Laboratory data revealed WBC count of 14,700/cumm(normal differential), otherwise normal CBC, electrolytes, renal and liver function tests. Blastomyces antibody by complement fixation, Blastomyces antibody test by immunodiffusion and Blastomyces urinary antigen were negative. Chest X-ray revealed diffuse interstitial infiltrates bilaterally and Chest CT with contrast revealed extensive bilateral multiple reticulo-nodular densities with hilar lymphadenopathy. Biopsies of skin lesions confirmed the presence of Blastomyces. Patient was intubated for respiratory distress and placed on mechanical ventilation; requiring high FiO2 and PEEP. Patient was initially treated with Amphotericin B IV but had a severe allergic reaction and was switched to itraconazole. Patient improved and was discharged on itraconazole. DISCUSSION: ARDS develops in <10% of patients with pulmonary blastomycosis and is associated with high mortality rate of 50 to 89% despite adequate antifungal therapy. Exaggerated cellular immune response is postulated has likely reason for clinical deterioration in blastomycosis induced ARDS. Antibody assays remain nonspecific and insensitive, and the confirmatory diagnostic test is growth of the organism in culture. In patients with severe ARDS with hypoxemia refractory to conventional modes of ventilation, ECMO can provide temporary pulmonary assistance to prolong the time for antifungals to work. The role of corticosteroids remains arguable. More than a third of patients who develop respiratory failure die within several days of hospitalization. Early diagnosis and treatment may help prevent significant morbidity and mortality. CONCLUSIONS: This case serves as a reminder to add exotic fungal infection to the list of differential diagnoses in patients with refractory pneumonia and ARDS.