Abstract | March 24, 2024

Disseminated Blastomycosis Meningitis in an Immunocompetent Young Male

Grace Tanguilig, BS, MS3, Tulane University School of Medicine, New Orleans, LA

Reema Kumari, MD, Neurology, PGY4, Tulane University School of Medicine, New Orleans, LA; Neda Hidarilak, MD, Assistant Professor, Neurology, Tulane University School of Medicine, New Orleans, LA

Learning Objectives

  1. Test for and keep fungal infections in their differential diagnosis for infectious presentations
  2. Treat possible fungal infections early to prevent disseminated disease

Introduction: Blastomycosis is a fungal disease most commonly caused by the dimorphic fungi Blastomyces dermatitidis, endemic to the Ohio and Mississippi River Valleys, Great Lakes region, and Southeastern United States. Dissemination occurs in 25-40% of symptomatic infections, and the most common extrapulmonary sites are skin, bone, the genitourinary tract, and the central nervous system. We present a case of blastomycosis meningitis in a 38-year-old immunocompetent male.

Case Presentation: A 38-year-old African American male with no past medical history was transferred from an outside hospital for concern of hydrocephalus on recent CT scan. This was following 5-6 months of diffuse headaches and generalized weakness, fever and chills, and multiple 3-5cm verrucous ulcerative lesions. His social history was significant only for working on a river barge in his home state of Mississippi; no recent travel or sick contacts. On physical exam, the patient was somnolent but arousable, with generalized weakness, pain with lateral movements of eyes, photophobia, and skin lesions. Lumbar puncture on admission revealed elevated opening pressure, elevated white blood cell count with lymphocytic predominance, elevated protein, and low glucose. He was started on RIPE therapy and dexamethasone for an initial differential diagnosis of disseminated tuberculosis versus neurosarcoidosis.

Final Diagnosis: Laboratory testing, including HIV, was persistently unremarkable. Finally, skin biopsy revealed broad budding yeast, confirming a diagnosis of blastomycosis, and he was started on liposomal Amphotericin B.

Management/Outcome: Management was complicated and involved frequent multidisciplinary discussions between infectious disease, neurology, the intensive care unit, and neurosurgery. Following initiation of amphotericin he experienced seizures and acute worsening of mental status, and was started on levetiracetam and lacosamide. He underwent serial lumbar punctures with the addition of acetazolamide for concern for increased cerebrospinal fluid pressure. Imaging was concerning for ischemic infarcts and potential vasculitis, and he completed a course of intravenous steroids. He also underwent multiple cerebral angiographies for worsening vasospasms, treated with intra-arterial verapamil, nicardipine, and balloon angioplasty. Unfortunately, he developed severe shock requiring intubation, four vasopressors, and an external ventricular drain. Sadly, he continued to decompensate, developed a brain herniation, and passed away on his 29th day of hospitalization.

References and Resources

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