Abstract Introduction Diffuse alveolar hemorrhage (DAH) is a life-threatening condition with multiple potential etiologies, most frequently rheumatologic disease or infection. For infectious etiologies, bacterial and viral infections are most commonly associated with the development of DAH. We describe a rare case of a fungal Blastomycosis-associated DAH complicated by disseminated disease. Case Description A 32-year-old male with no prior history presented to the emergency department with shortness of breath and significant weight loss. He was hypoxic and in diabetic ketoacidosis with imaging showing diffuse ground glass opacities (Figure 1a). He was managed with an insulin infusion and started on broad-spectrum antibiotics while further workup was pursued. His initial antibiotic regimen included vancomycin, piperacillin-tazobactam, and azithromycin. However, he required intubation for persistent severe hypoxemia on high-flow nasal cannula and underwent bronchoscopy with bronchoalveolar lavage (BAL), which showed sequential progressively bloody aliquots consistent with DAH (Figure 1b). He had escalating oxygen requirements with a PaO2/FiO2 ratio of 0.58 indicative of severe acute respiratory distress syndrome (ARDS). The decision was made to treat with corticosteroids, and he was also empirically started on liposomal amphotericin B for fungal coverage. He underwent paralysis and pronation and was further considered for extracorporeal membrane oxygenation (ECMO).His laboratory workup was significant for Blastomyces antigen in the urine, Blastomyces dermatidis in BAL specimens, and fungal yeast forms on transbronchial biopsy specimens. Autoimmune workup including ANCAs and other infectious workup including HIV, BAL culture, and Mycobacterial studies were unrevealing. He was later found to have femoral involvement from a bone biopsy, rendering his disease disseminated. The patient clinically improved on liposomal amphotericin B and ultimately did not require ECMO. He was extubated and later discharged to an acute rehabilitation facility on a prolonged course of itraconazole. Discussion This case highlights a unique presentation of acute disseminated Blastomycosis complicated by DAH and ARDS in a patient from an endemic region, the Great Lakes, with poorly controlled diabetes. Diabetes has been described as an independent risk factor for the development of severe or disseminated Blastomycosis. Inoculation with Blastomyces spp. occurs via inhalation of conidia after disruption of soil which interestingly did not apply to our patient, as his exposure history was unremarkable. Maintaining a broad differential for the many etiologies of ARDS that can overlap with DAH is vital. Early empiric initiation of antifungal coverage can be lifesaving. Studying such cases can inform future management of this life-threatening condition. This abstract is funded by: None
Noor et al. (Fri,) studied this question.