Abstract Introduction Blastomycosis is a systemic fungal infection caused by Blastomyces dermatitidis. Its incidence has markedly increased in the upper Midwest, rising from 0.5 to 6.8 cases per 100,000 people annually between 2013 and 2023. While pulmonary involvement is common, the development of acute respiratory distress syndrome (ARDS) is uncommon but carries a very high mortality rate. We present a case of severe blastomycosis-related ARDS managed successfully with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in conjunction with antifungal therapy. Case Presentation A 46-year-old man with type 2 diabetes and a history of tobacco use presented with two weeks of worsening dyspnea and cough. He was initially treated for community acquired pneumonia with outpatient antibiotics but was readmitted shortly afterward with progressive respiratory distress. Chest computed tomography revealed multifocal bilateral consolidations (Figure 1). Initial infectious workups were negative. His condition rapidly deteriorated, necessitating intubation and transfer to our intensive care unit. He developed severe ARDS and septic shock, requiring mechanical ventilation. VV-ECMO was initiated on hospital day 2 due to persistent hypoxia. Bronchoscopy with bronchoalveolar lavage (BAL) was performed, and he continued on broad-spectrum antibiotics. BAL cultures later grew Candida albicans and Blastomyces dermatitidis; serologic testing for Blastomyces was positive. Amphotericin B therapy was initiated. His respiratory status gradually improved, allowing ECMO decannulation on day 13, and subsequent weaning from mechanical ventilation to Optiflow. He was transitioned to oral itraconazole maintenance therapy. Discussion Approximately 10% of hospitalized patients with pulmonary blastomycosis develop ARDS, with reported mortality rates ranging from 50% to 90% which is significantly higher than ARDS from other causes. Literatures reports that immunosuppression, type 2 diabetes, and multilobar pneumonia increase the risk of ICU admission. Mortality is often related to early, refractory respiratory failure. Previous studies have shown poor outcomes among patients requiring mechanical ventilation, with mortality rates around 40% without ECMO use in these cohorts. In our case, VV-ECMO provided critical oxygenation support during severe hypoxemia refractory to conventional ventilation. This allowed for lungs to rest and served as a bridge to recovery while antifungal therapy took effect. Early initiation of ECMO in blastomycosis related ARDS may be life saving when combined with timely antifungal treatment. Conclusion Blastomycosis-induced ARDS is rare but life-threatening. This case underscores the importance of early recognition and aggressive management, where prompt antifungal initiation and timely use of VV-ECMO can significantly improve outcomes in otherwise fatal cases. This abstract is funded by: None
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