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There’s a Fungus Among Us - Peripartum Management of a Patient with Disseminated Blastomycosis
Abstract Number: T-79
Abstract Type: Case Report/Case Series
Introduction: Blastomycosis is a systemic disease caused by the fungus Blastomyces dermatitidis that is endemic in the Ohio and Mississippi River valley and Canadian regions that border the Great Lakes. Infection occurs by inhalation of spores from soil, and the disease presents as an acute or chronic pneumonia. The presentation of blastomycosis varies; immunocompromised patients may present with disseminated disease involving skin, bones, genitourinary, and central nervous system. In severe cases, vertical transmission can occur.
Case report: The patient is a healthy 35 year-old G2P1 who presented at 38 weeks’ gestation with night sweats, weight loss, and cutaneous lesions on her arm, forehead, and right buttock. CXR revealed multifocal lesions and a RUL consolidation. Biopsy of the skin lesions confirmed a diagnosis of blastomycosis. The patient was started on amphotericin B 5 mg/kg daily at the recommendation of the infectious disease team. The following day she developed a headache and uterine contractions. The infectious disease team recommended brain MRI, as well as CSF sampling to rule out CNS involvement. Brain MRI, however, was deferred due to concern for imminent labor in the setting of uterine contractions, and CSF sampling was deferred for concern of creating a CSF leak that could lead to postdural puncture headache. Two days later, the patient went into spontaneous labor. A combined spinal epidural (CSE) was performed for labor analgesia. 5 ml of CSF was collected via 27G Whitacre during CSE placement and sent for evaluation. The patient subsequently underwent NSVD with APGARS 9/9. Her post-partum course was uncomplicated, and she was discharged to home on post-partum day #2. The CSF was negative for blastomycosis.
Discussion: There are only a handful of case reports on the management of blastomycosis in pregnancy, none of which address the safety of neuraxial analgesia in patients with disseminated disease. Neuraxial labor analgesia was used in this case, as the patient did not show signs of increased intracranial pressure (ICP) and had been on antibiotic therapy for three days prior. It also allowed for CSF evaluation to rule out CNS involvement. Neuraxial techniques appear to be safe in patients with disseminated blastomycosis without evidence of increased ICP.
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Surprenant D, et al. Case Rep Dermatol 2015;72(5):107-12