Radical treatment for blastomycosis following unsuccessful liposomal amphotericin

• Published in: The Lancet infectious diseases 2022-12, Vol.22 (12), p.e377-e381
• Main Authors: Chew, Christopher, Thapa, Nikhilesh, Ogbuagu, Henry, Varghese, Merin, Patel, Dhaval, Abbas, Raza, Oh, Jason, Teshome, Molla, Mohammed, Khaja, Saleem, Sohail, Aggarwal, Deepak, Barns, Barry, McDonald, April, Ormenisan-Gherasim, Claudia
• Format: Article
• Language: English
• Subjects: Adult; Amphotericin B; Amphotericin B - therapeutic use; Antibiotics; Antibodies; Antifungal Agents - therapeutic use; Antigens; Bacteria; Blastomycosis; Blastomycosis - diagnosis; Blastomycosis - drug therapy; Dermatitis; Diabetes; Extracorporeal membrane oxygenation; Extubation; Fungi; Health services; Humans; Hypoxia; Immunocompromised hosts; Infectious diseases; Inhalation; Intravenous administration; Itraconazole; Lavage; Lungs; Male; Medical imaging; Morphology; Mortality; Oxygenation; Patients; Pneumonia; Respiration; Respiratory diseases; Respiratory distress syndrome; Respiratory Distress Syndrome - drug therapy; Respiratory function; Spores; Tuberculosis; Urine
• ISSN: 1473-3099; 1474-4457
• DOI: 10.1016/S1473-3099(22)00352-8

Pulmonary blastomycosis is a respiratory disease that is caused by the fungus Blastomyces spp, which is acquired through inhalation of the fungal spores. Blastomycosis is relatively uncommon, with yearly incidence rate of 1–2 cases per 100 000 people. Blastomycosis is a disease that is endemic to the midwest and southern regions of the USA, most commonly affecting immunocompromised patients. About 50% of patients are asymptomatic, but for those who progress to acute respiratory distress syndrome (ARDS) mortality can be as high as 80%. Patients with severe blastomycosis are initially treated with intravenous amphotericin B, followed by long-term itraconazole maintenance therapy. In this Grand Round, we present the case of an immunocompetent 35-year-old man diagnosed with chronic pulmonary blastomycosis who had a poor response to 10 days of intravenous liposomal amphotericin B (L-AmB). He was endotracheally intubated and eventually cannulated for extracorporeal membrane oxygenation (ECMO), due to worsening respiratory function. L-AmB was replaced with a continuous infusion of intravenous amphotericin B deoxycholate (AmB-d). He improved significantly and was decannulated from ECMO on day 9 of AmBd continuous infusion and extubated on day 12 Although L-AmB is considered first-line treatment for blastomycosis, mortality remains high for patients with ARDS associated with blastomycosis. This case highlights the importance of considering AmB-d continuous infusions for patients with severe blastomycosis who might have poor clinical responses to L-AmB.