Potentially Preventable? A Case of Recurrent Blastomycosis Involving the Central Nervous System

Blastomycosis is a disease caused by infection with thermally dimorphic fungi belonging to the genus Blastomyces. Central nervous system (CNS) involvement occurs in an estimated 1% to 10% of patients with blastomycosis, and treatment requires at least 12 months of antifungal therapy.

We describe a 32-year-old male who presented with recurrent blastomycosis involving the CNS.

The patient was initially diagnosed with pulmonary blastomycosis with possible involvement of the CNS approximately 1 year prior to his current presentation. At that time, he was treated with amphotericin B deoxycholate and then subsequently transitioned to oral voriconazole. On discharge he only filled his voriconazole prescription for 8 weeks out of a planned year-long treatment course, due to an inability to afford it. He subsequently re-presented with symptoms of headache, nausea, and ataxia, and was found to have a right-sided cerebellar abscess. The abscess was drained and Blastomyces sp was isolated on culture. Following surgery, the patient was once again started on voriconazole after completing a course of liposomal amphotericin B. Social work was engaged early on during this admission. Fortunately, the patient's financial situation had improved and medication cost was no longer a barrier. When seen in follow-up, he remained on oral therapy and was doing well.

A case of recurrent blastomycosis with involvement of the CNS is presented, where treatment failure occurred due to an inability of the patient to afford the required medication. Medication cost should always be considered and discussed with a patient when developing a treatment plan.