Disseminated Blastomycosis Dermatitidis Causing Hepatitis in an Immunocompromised Patient: 763

We present a case of disseminated blastomycosis causing acute hepatitis in an immunocompromised patient. A 46 year-old female with Crohn's disease on adalimumab and methotrexate presented with chest pain, shortness of breath and fevers for one week. Physical examination revealed anicteric sclera, normal heart, lung, and abdominal examinations. Labs on admission showed a total serum bilirubin of 0.7 mg/dl, alkaline phosphatase (ALP) of 313units/L, and a serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of 655units/L and 961units/L, respectively. Computer tomography scan of the chest, abdomen and pelvis revealed mild fatty liver and diffuse gallbladder wall thickening, but also a right lower lobe infiltrate and mild effusion. A hepatobiliary iminodiacetic acid scan was normal. Autoimmune liver and viral hepatitis panels were negative. Urine histoplasma antigen was positive. The patient had a bronchoscopy with bronchoalveolar lavage with cultures sent. She was started on liposomal amphotericin B. Adalimumab and methotrexate were not continued. Her AST, ALT and conjugated bilirubin continued to increase to 1361, 914 and 7.5 respectively. She clinically improved despite the increasing transaminases. Blastomyces dermatitidis antigen was positive and cultures eventually grew blastomyces dermatitidis. Amphotericin B was changed to oral itraconazole. She was discharged home with improved transaminases. Our patient presented with mild flu like symptoms, which is a common presentation for blastomycosis, but she also had markedly elevated transaminases. The most common extra-pulmonary sites of blastomyces in humans are skin, skeleton, male genitourinary system, and central nervous system. Liver involvement is rare. A far more common infectious source of both lung and liver is histoplasmosis, however this was not the cause in our patient. A false positive histoplasma urine antigen can occur secondary to cross reactivity with blastomyces. The initial treatment for disseminated blastomycosis is IV amphotericin B. Two other cases of patients presenting with acute blastomycosis pneumonia and elevated transaminases are reported, however the transaminase elevation was not attributed to the infection. The first is a case of a 44 year-old white female who presented with fever, cough and alcoholic hepatitis and ultimately died of delirium tremens. Her transaminase elevation was attributed to the alcoholic hepatitis. The second case involves a seventeen-year-old male who presented with cough, hemoptysis, weight loss, and skin lesions and developed elevated transaminases following treatment with amphotericin B. To our knowledge, this is the first reported case of acute hepatitis caused by disseminated blastomycosis.