A case of mistaken identity: pulmonary blastomycosis diagnosed as pulmonary cryptococcosis
Abstract
TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Community acquired pneumonia (CAP) has a wide range of differential diagnosis with high potential for misdiagnosis. We report a case of Blastomycosis in an Appalachian hunter who was misdiagnosed with bacterial and Cryptococcal pneumonia. This case highlights the importance of evaluating CAP etiologies based on patients' epidemiological risks. CASE PRESENTATION: A 32-year-old West Virginian man with a history of recurrent sinusitis, body-mass index of 18, current smoker, and avid hunter presented with dyspnea and dry cough. Initially, at an outside facility 3 weeks prior, chest x-ray showed a left upper lobe consolidation. He was prescribed a 10-day course of levofloxacin and steroid taper, but his symptoms did not improve. Further evaluation with computed tomography (CT) chest showed a 1.6-centimeter necrotic lymph node in the subcarinal area and consolidation in the left upper lobe and lingula. He was admitted and received empiric intravenous vancomycin, piperacillin-tazobactam, and azithromycin. Severe acute respiratory syndrome coronavirus 2 and human immunodeficiency virus tests were negative. Initial pathology read of lingula biopsy was stratified squamous epithelia with enmeshed clusters of cysts with double walls and inclusion bodies suggestive of Cryptococcus neoformans. Antibiotics were discontinued and fluconazole was started, but he developed a fever of 103⁰ Fahrenheit. Then, he was…
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