Blastomycosis is an endemic mycotic infection caused by inhalation of thermally dimorphic fungi from the genus Blastomyces. Blastomyces dermatitidis is the species most related to human infection in the USA and North America. Adult respiratory distress syndrome (ARDS) is a rare complication of blastomycosis and is associated with high mortality. Due to its rarity, evidence-based guidelines for diagnosing and treating ARDS associated with blastomycosis are scarce. In this case presentation, a 22-year-old male with a history of chronic cannabis use presented with severe respiratory symptoms, initially treated as community-acquired pneumonia. Despite antibiotic treatment, his condition deteriorated, necessitating intubation and resulting in the development of ARDS. A delayed diagnosis of pulmonary blastomycosis was confirmed through polymerase chain reaction testing. Treatment with amphotericin B and corticosteroids proved successful in addressing the fungal infection, leading to the recovery of the patient from his severe clinical condition. This case highlights the challenges associated with diagnosing and treating blastomycosis, particularly when complicated by ARDS, emphasizing the importance of considering fungal infections in the differential diagnosis of non-responsive pulmonary infections. Additionally, it suggests the potential utility of corticosteroids in severe cases and emphasizes the crucial role of early diagnosis and a combination of diagnostic modalities for the timely management of this rare and potentially life-threatening condition.

Blastomycosis is an endemic mycosis in certain parts of North America. The dimorphic fungus can manifest with both pulmonary and extrapulmonary features. We present the case of a 24-year-old African American male with a history of vaping and daily marijuana who presented with hemoptysis and a cough of one-week duration. He was initially treated as community-acquired pneumonia (CAP). The patient had a bronchoscopy with bronchoalveolar lavage (BAL) done in the posterior segment of the right upper lobe. Cultures grew methicillin-resistant Staphylococcus aureus (MRSA), followed by Blastomyces dermatitidis in the histopathologic examination. Chronic pulmonary blastomycosis may present with hemoptysis, weight loss, chronic cough, and night sweats, along with upper lobe predominant cavitation. We have to exclude tuberculosis (TB), lung cancer, and chronic pulmonary histoplasmosis. This case epitomizes many classic perils in the identification of pulmonary blastomycosis. The patient was being treated with itraconazole 200 mg BID for 12 months as per infectious disease suggestion. The patient is nine months into treatment. At six months, his chest computed tomography (CT) revealed a reduction in size from 5.0 × 5.3 cm to 4.2 × 4.0 cm. Although there are no articles supporting increased secondary bacterial infections with underlying fungal infections, more research needs to be done to find any associated features.

Necrotizing pneumonia is a rare but potentially life-threatening complication of pulmonary blastomycosis, a fungal infection caused by inhaling spores of the fungus Blastomyces dermatitidis. This case report describes a 56-year-old male who presented with worsening malaise, subjective fevers and chills, night sweats, and a productive cough. Further evaluation revealed a right upper lobe necrotizing pneumonia secondary to pulmonary blastomycosis.

This case report highlights the importance of a detailed travel history and the need to revisit the differential diagnosis when there is an unexpected clinical course. A previously healthy 15-year-old male presented to a hospital in Florida with a fever, cough, and shortness of breath. He was seen multiple times at urgent care centers and treated with steroids and antibiotics for community-acquired pneumonia (CAP). The patient\'s chest X-rays and CT showed necrotizing pneumonia with pleural effusion, which required a chest tube. Despite broadening coverage for possible resistant organisms, his fevers and hypoxia continued. On day 14 of hospitalization, a bronchoscopy was performed, which led to the diagnosis of blastomycosis. History was revisited, and a specific travel history was obtained. The patient had been camping with his father on the Minnesota/Canada border a few months prior to his presentation. Blastomycosis is caused by a dimorphic fungus endemic in certain parts of the United States including areas surrounding the Mississippi and Ohio River valleys, some southeastern states, and areas bordering the Great Lakes. Autochthonous blastomycosis is not seen in Florida. The infection is acquired by inhalation of the organism and is associated with outdoor occupation and recreation. As with other infections with specific endemic distribution, the diagnosis of blastomycosis can be delayed if the epidemiologic link is not established. Questions about travel history need to be very specific as this could be critical in establishing the appropriate differential diagnosis and leading the workup. The patient\'s lack of improvement despite appropriate antibiotic therapy for CAP led to questioning the working diagnosis, revisiting the history, and expanding the workup, which was critical in this case.

Blastomycosis is caused by Blastomyces dermatitidis, which is endemic in certain areas in North America. It usually causes lung infection, and it can disseminate to other organs in immunocompromised individuals. Common sites for dissemination include skin, central nervous system (CNS), and bone. Dermatological spread is the commonest site for extrapulmonary spread. The diagnosis can be easily missed due to nonspecific presentation and variable dermatological presentations. Treatment is necessary even if the patient has improvement in symptoms without previous treatment. We present a case of disseminated blastomycosis in a 40-year-old male without known risk factors that went undiagnosed for over a year.

Blastomycosis is a systemic mycosis endemic to the Midwestern and South Central United States. Infection is caused by inhaling spores of Blastomyces dermatitidis (B. dermatitidis) that inhabit soil. Acute respiratory distress syndrome (ARDS) is a rare complication of pulmonary blastomycosis with a significantly high mortality rate. We present a case of blastomycosis associated with severe ARDS treated with traditional prone position ventilation (PPV) and neurally adjusted ventilator assist (NAVA) along with antifungal therapy, steroids, and supportive care in a rural setting with no access to extracorporeal membrane oxygenation (ECMO). This case demonstrates that traditional therapies such as prone position ventilation can help patients with blastomycosis-associated ARDS especially in rural settings where advanced therapies such as ECMO are lacking. The use of NAVA in blastomycosis-associated ARDS needs further research.

Blastomycosis is caused by Blastomyces dermatitidis, a dimorphic fungus that primarily causes pulmonary disease. Cutaneous blastomycosis is infrequent and tends to be misdiagnosed given its similar presentation to other cutaneous fungal infections and malignancies. A 51-year-old woman presented with a two-month history of disfiguring nasal lesions. The patient had a past medical history of cervical cancer which was currently in remission. Social history was significant for frequent travel throughout the United States as a truck driver, including the Midwest. The patient had a non-purulent verrucous plaque on her right nare, which was painless and mildly pruritic. Superficial cultures grew Enterococcus faecalis, prompting treatment with oral cephalexin and topical mupirocin. Given no relief, the patient was started on clindamycin followed by Augmentin. Both treatments were unsuccessful.  The lesion was then biopsied and fungal cultures were sent. The biopsy showed broad-based budding yeast surrounded by pseudoepitheliomatous hyperplasia, and cultures grew Blastomyces dermatitidis. The patient was initiated on 200 mg itraconazole thrice daily for the first three days, followed by 200 mg itraconazole twice daily for the next 12 months. She showed notable improvement within a month. This patient was initially misdiagnosed with bacterial infection due to superficial cultures, which were likely a contaminant. It was only after a biopsy that the patient was accurately diagnosed. Besides bacterial infection, cutaneous blastomycosis is often confused with coccidioidomycosis, mycobacterial infection, or squamous cell carcinoma. In patients such as ours who are presenting with persistent facial lesions in the setting of frequent travel history, fungal etiologies should be high on the differential. A biopsy and fungal cultures should be sent at the outset for accurate diagnosis and treatment.

Blastomycosis is an uncommon granulomatous disease caused by infection with thermally dimorphic fungi of the genus Blastomyces. Although pulmonary infections from Blastomyces dermatitidis are uncommon, it is important to understand the geographical distribution, presentation, diagnosis, and management of treating this condition. We report a case of fulminant blastomycosis after high inoculum inhalation, with involvement of the prostate on presentation, which progressed to acute respiratory distress syndrome.

In a rural medical center in Upstate New York, we observed an increase in pulmonary blastomycosis cases. Herein, we highlight the increased prevalence of blastomycosis in our region, and our experience with the diagnostic dilemma resulting in delayed diagnosis. This delay may have resulted in an increased mortality. A high index of suspicion may help hasten the diagnosis in an otherwise nonendemic area. A single-center retrospective case series of all patients diagnosed with culture-proven blastomycosis is reported at the Bassett Medical Center from 2007 to 2019. Eight cases of confirmed pulmonary blastomycosis were identified. All patients resided in a rural area along the Susquehanna River Basin. Only one case had a travel history to an endemic state. Males accounted for 100% of cases. There was a 50% mortality rate from acute respiratory distress syndrome. Bronchoalveolar lavage (BAL) reliably made the diagnosis. About 40% of patients had a false-negative blastomycosis serology. There was an average delay of 2.5 months from presentation to correct diagnosis due to a lack of consideration for blastomycosis. BAL resulted in a correct diagnosis, while serology was not reliable to exclude the diagnosis. Physicians should include blastomycosis in the diagnostic differential cases of nonresolving pneumonia in Upstate New York, an area not previously considered as endemic. Bronchoalveolar remains the evaluation method of choice if blastomycosis is suspected.

OBJECTIVE: Diagnosing pulmonary blastomycosis (PB) requires the detection of Blastomyces dermatitidis in pulmonary secretions or tissue, which can be achieved via bronchoscopic procedures like bronchoalveolar lavage (BAL) or brush and transbronchial biopsy (TBBx). This descriptive study retrieved the data of PB that was diagnosed by bronchoscopy to define which bronchoscopic procedure produced the highest yield.
METHODS: Retrospectively, all patients diagnosed with PB via bronchoscopic approach were identified. Non-invasive BAL was referred to when performed first in the order of bronchoscopic procedures, and invasive BAL was used when it was performed after other bronchoscopic procedures.
RESULTS: A total of 111 patients were included in the study. BAL produced the highest yield of all bronchoscopic procedures (>87%), regardless if it was performed first in order (non-invasive, 87.3%) or not (invasive BAL, 89.6%) (p = 0.43). Performing bronchoscopy and BAL earlier in the course of the disease resulted in a significantly better diagnostic yield.
CONCLUSIONS: BAL is probably enough to diagnose PB. Also, it had the best yield when performed earlier, regardless of whether it was performed first in order or not. BAL culture had a better yield in detecting Blastomyces dermatitidis over fungal stain and cytology.