22 April 2023
: Case report 
Classical Presentation of Disseminated Blastomycosis in a 44-Year-Old Healthy Man 3 Months After Diagnosis of COVID-19
Challenging differential diagnosis, Rare disease
Diana Fan1ABDEF, Ali Ahmad
1ABDE, Jared Frisby2DEF, Kavita Darji3BE, Ashley Ojeaga3BE, Ramona Behshad3BE, M. Yadira Hurley3BE, Mallory Abate3BE, Paul Kunnath1AE*
DOI: 10.12659/AJCR.938659
Am J Case Rep 2023; 24:e938659
Table 3. A comprehensive account of events from the entire disease course of a 44-year-old male with a diagnosis of blastomycosis, as described in this case report. Day 0 is marked as symptom onset. Following events are listed in chronological order according to days since symptom onset.
| Day | Events |
|---|---|
| 0 | Developed symptoms: cough, headache, congestion, hemoptysis |
| 3 | Visit to primary care provider, where he tested positive for COVID-19. Started on Doxycycline 100mg BID for 7 days.CT at this time showed L upper lobe mass indeterminate for malignancy vs rounded bacterial pneumonia |
| 85 | Developed papulopustular rash |
| 92 | Presenting symptoms to our ED: persistent cough and rash |
| Outpatient CT showing: Substantial progression of consolidation/atelectasis and peripheral peribronchial thickening and nodularity in the left upper lobe and lingula since 10/21/21. Within the area of consolidation are increasing air collections suggesting lung necrosis New infiltrate & atelectasis in the right upper lobe and left lower lobe. Focal bronchial dilation vs early developing cavitary nodules | |
| 93 | Imaging showing consolidative opacities in bilateral upper lobes concerning for multifocal necrotizing pneumonia and multifocal nodules within the subcutaneous fat, with some contacting the skin surface correlating with patient’s rash |
| 97 | Bronchoscopy done with pulmonology, showing erythematous airways in left upper lobe and yellow-tinged secretions |
| 98 | Blastomyces Dermatitidis antigen detected. Began IV liposomal amphotericin B treatment |
| MRI with contrast showing multiple supratentorial and infratentorial enhancing lesions, concerning for septic emboli | |
| 122 | Nephrology consulted for developing acute kidney injury secondary to amphotericin B administrationKidney ultrasound showing normal renal size with no evidence of nephrolithiasis, hydronephrosis, or renal mass |
| 123 | Repeat imaging showing significant decrease in the size & number of enhancing brain lesionsInterval improved aeration of bilateral upper lobes with residual consolidation |
| 125 | Discharged after completion of IV amphotericin B with a plan to continue oral Itraconazole for 12 monthsBaseline Creatinine 1.0→1.6 at discharge |
| 173 | Follow up with pulmonology with improvement of symptoms – cough has resolved. No neurologic symptoms.Dermatologic lesions improved |
| 193 | Follow up with nephrology. No urinary symptoms. Creatinine 1.4 from 1.6 at discharge |