Failure of ketoconazole in an immunosuppressed patient with pulmonary blastomycosis

A renal transplant recipient presented with pulmonary blastomycosis. Because of recent data suggesting a role for ketoconazole in the treatment of blastomycosis and concern for preserving her functioning renal transplant, she was started on therapy with ketoconazole, 400 mg daily. After four months of continuous therapy, she developed skin and laryngeal involvement requiring emergency tracheostomy; subsequent therapy with amphotericin B resulted in resolution of her disease. This is an example of life-threatening progression of blastomycosis in an immunosuppressed patient during ketoconazole therapy.