Successful bilateral lung transplantation in a patient with severe pulmonary blastomycosis

Severe pulmonary blastomycosis may progress to acute respiratory distress syndrome (ARDS) necessitating prolonged extracorporeal support, and ultimately lead to irreversible pulmonary injury. Whether these patients should proceed to lung transplantation remains controversial. We report a 38-year-old man with type 2 diabetes mellitus who developed fulminant pulmonary blastomycosis following environmental exposure in Ontario, Canada. Despite prolonged treatment with liposomal amphotericin B and azole therapy, his course was complicated by respiratory failure requiring mechanical ventilation, and prolonged venovenous extracorporeal membrane oxygenation (VV-ECMO), with concomitant recurrent ventilator-associated bacterial pneumonias and treatment-related nephrotoxicity. Although microbiologic markers gradually improved, including declining urinary Blastomyces antigen levels and negative respiratory fungal cultures, lung function recovery failed to occur. Ongoing uncertainty persisted regarding uncontrolled infection versus irreversible pulmonary injury. The patient ultimately underwent successful bilateral lung transplantation while receiving antifungal therapy. Post-transplant recovery progressed slowly but smoothly, with liberation from ECMO and no evidence of recurrent fungal disease. This case suggests that concern for invasive fungal infection persistence should not automatically preclude lung transplantation as a means of survival for irreversible lung injury when assessment supports favorable microbiologic control.