58 year-old male with recurrent blastomycosis and abnormal immune workup. He was referred by ID after his third episode of blastomycosis.
In 11/2010, he was diagnosed with cutaneous blastomycosis treated with itraconazole for 12 months. Eight months after treatment completion, he had recurrent cutaneous lesions and biopsies showed blastomycosis for which he was treated with itraconazole for about 18 months from 9/2012 to 3/2014. Two months after completing this course, he was diagnosed with pulmonary blastomycosis after he developed headaches, fever, mild cough, and sweats and chest CT showed bilaterally pulmonary nodules which were biopsied. He was started on itraconazole again and immune workup was checked by ID.
He had normal immunoglobulins (IgA 335, IgG 978, IgM 98), low absolute lymphocytes at 533 (850-3900), low absolute CD4 count of 201, low RBC 3.84, high platelets of 444, WBC of 5900, and lymphocytes of 500. Total lymphocyte count measured on CBC during the months of May and June, 2014 has ranged from 300 (5/12), 200 (5/14), 700 (5/19), 500 (5/20), 300 (5/21), and more recently 500 (6/5), and flexitest showed low total lymphocytes at 421 with low CD19 cells 80 (19%), low CD3 cells 282 (67%). Inflammatory markers such as ESR are increased and ANA has always been negative. I did not see any HIV testing in our system; however I was told that HIV testing was negative. Imaging does not show lymphadenopathy. He denies a history of other infections such as skin, sinopulmonary, urinary, or other infections aside from three episodes of blastomycosis.
He is an avid gardener and spends time in the vegetable garden and with fresh compost pile, and spreading mulch. In April 2014 since completing his most recent itraconazole, he began working with the compost again.
Notably, he was diagnosed with sarcoidosis in 1995 after biopsy was done “in the chest for enlarged lymph nodes” although records were not available. In 2003, symptoms increased and he was treated with a tapering course of prednisone over 5 years until 2009. He has travelled to Mexico, South Africa, Germany, and Canada in the past 8 years. blastomycosis.
It seems itraconazole is effective in treating his infections as symptoms improve, however he has recurrent blastomycosis which could be an opportunistic infection in the setting of immune deficiency. It seems he needs to be worked up for other causes of CD4 lymphocytopenia including confirmation of HIV status and assesement of cellular immunity. Before ordering further labs, I want to ask what further blood work would you recommend in the analysis of his immune deficiency. It seems less likely, but would 5 years of prednisone be enough to suppress him immune system years later. Also we plan to look for secondary causes of lymphocytopenia including bone marrow evaluation and malignancy workup. Please advise on this interesting case as any input would be welcome and helpful.