Histoplasmosis or Blastomycosis in a Patient With Left Ventricular Assist Device

Histoplasma and Blastomyces are environmentally acquired fungi that can cause a wide spectrum of clinical disease, ranging from asymptomatic to life-threatening illness. These fungal infections are rarely encountered in patients with a left ventricular assist device (LVAD), with only one case of histoplasmosis reported in the literature. We report histoplasmosis or blastomycosis with possible infection of the underlying LVAD. The patient is a 55-year-old male with an implantable cardioverter-defibrillator (ICD) and an LVAD for sarcoid-related cardiomyopathy. He was on infliximab for sarcoidosis and presented with a fever of unclear etiology along with fatigue, poor appetite, and weight loss. Blood and urine cultures were negative. There was no drainage of the drive line (DL) exit site. A CT of the chest and abdomen showed nonspecific pulmonary ground-glass opacities and no intra-abdominal abscess. Eventually, urine Histoplasma and serum Blastomyces antigens returned positive. The patient was started on itraconazole, and infliximab was stopped. The patient started improving, and Histoplasma and Blastomyces antigen levels started declining. Since the fungal blood culture was negative and there was no end-organ disease for biopsy or fungal culture, we could not distinguish between histoplasmosis and blastomycosis. This case underscores the rarity of histoplasmosis/blastomycosis in patients with LVADs.