(829) Battling Blastomycosis: A Unique Case Series of Two Critically Ill Sisters, One Rescued by ECMO

Introduction: Blastomycosis is a fungal infection endemic to the Ohio and Mississippi River Valleys, Great Lakes, and southern United States. Of the many clinical presentations, pulmonary blastomycosis is most common, with severity ranging from asymptomatic pulmonary infiltrates (up to 50% of cases) to complete respiratory or circulatory collapse necessitating extracorporeal membrane oxygenation (ECMO).

Description: A 9-year-old female and her 11-year-old sister presented to their local hospital with similar symptoms: flank pain, cough and congestion. They were each diagnosed with community acquired pneumonia and started on antibiotics. The youngest was admitted locally for supplemental oxygen, failed to respond to initial antibiotic treatment, and was transferred to our tertiary care center for worsening oxygen requirement. The eldest was treated as an outpatient, failed to respond to antibiotic treatment, then presented directly to our center. They shared a common extensive exposure history, and therefore were started on broad empiric antimicrobials, including antifungals. Both sisters developed pediatric acute respiratory distress syndrome (PARDS) requiring intubation. The youngest improved with conventional ventilation and vasoactive medications. The eldest failed both conventional ventilation and high frequency oscillatory ventilation, and ultimately required venovenous ECMO cannulation. Testing confirmed a diagnosis of blastomycosis, treatment was narrowed, and each patient gradually improved until discharge home on an extended course of itraconazole.

Discussion: Blastomycosis-related ARDS is often not considered until late in the disease course, yet early recognition and treatment is essential to maximize recovery. Here we present the successful treatment of two sisters with severe pulmonary blastomycosis, including the youngest reported patient to survive treatment with ECMO. Their favorable outcomes are likely due, at least partially, to early initiation of empiric antifungal therapy and prompt respiratory supportive care, including ECMO. This emphasizes the importance of including fungal infections in the differential diagnosis of severe pneumonia/PARDS with respiratory failure, particularly in endemic areas.