DISSEMINATED BLASTOMYCOSIS: A RARE CAUSE OF CENTRAL DIABETES INSIPIDUS

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 164-196-Pituitary
Basic/Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-178
Jana Wright Phillips*1, Lance Atchley2, Geraldo Holguin3, Trayton Mains3, Frederick Asher2, Christian A Koch4, Angela Subauste3 and Jose S Subauste5
1Univ of MS Med Ctr, Jackson, MS, 2UMMC Department of Medicine, Jackson, MS, 3UMMC, Jackson, MS, 4Univ of Mississippi Med Ctr, Jackson, MS, 5G.V. Sonny Montgomery VA Medical Center, Jackson, MS
Background:  

Blastomycosis dermatitidis is a fungus which most commonly affects the pulmonary system but can also have endocrine consequences.  

Case:

A 48-yo man presented to an outside hospital with dyspnea and cough despite two courses of PO antibiotics as an outpatient for pneumonia.  He was treated with broad-spectrum IV antibiotics but developed multiple cutaneous nodules.  Skin biopsy was consistent with Sweet syndrome (acute febrile neutrophilic dermatosis), and treatment with prednisone was initiated. His dyspnea and skin lesions subsequently worsened, and he was transferred to UMMC.  Transbronchial and cutaneous biopsies were consistent with blastomycosis, and treatment with amphotericin B was initiated. The day prior to ampho B initiation, the pt began c/o polyuria and polydipsia. Serum osmo was 299 mosm/kg  (n 280-295mosm/kg), and urine osmo was 96 mosm/kg, consistent with diabetes insipidus. He responded well to subcutaneous desmopressin (Uosmo 271 mOsm/kg after first dose) and later to oral desmopressin, confirming a diagnosis of central DI. MRI pituitary revealed thickened enhancing infundibulum and loss of the posterior pituitary bright spot on T1 images. His glucocorticoid was tapered slowly following hospital discharge. He is currently completing an extended course of itraconazole and has had marked improvement in cutaneous lesions and dyspnea. His central DI persists but is well controlled with DDAVP 0.2 mcg PO qhs. Recent thyroid function tests were normal, and he has no clinical signs or symptoms of adrenal insufficiency.

Discussion:

Fungal infections should be considered in the differential diagnosis of central DI. Cryptococcal meningitis, most often seen in HIV patients, is a known cause of central DI (3). Invasive fungal infections such as aspergillosis and rhinocerebral zygomycosis can also cause DI (2,4). To our knowledge there is only one reported case of central DI reported due to disseminated blastomycosis (1).  Lemos and colleagues report in their review that pituitary involvement occurs in only 3% of patients with blastomycosis (5). Other CNS manifestations of blastomycosis including abscess, meningitis, and spinal cord involvement, are rare and mostly seen in immunocompromised hosts (6). In patients with severe fungal infections including disseminated blastomycosis, clinicians should be mindful of the possibility of DI and monitor closely for symptoms of polyuria and polydipsia.

1. Kelly, PM. Systemic blastomycosis with associated diabetes insipidus. Annals of Internal Medicine. 1982; 96 (1):66-67. 2. Szporni A, et al. Aspergillosis of the sphenoid sinus: presentation as a pituitary mass. Orv Hetil. 2000; 141(42):2299-301. 3. Juffermans NP, et al. Diabetes insipidus as a complication of cryptococcal meningitis in an HIV-infected patient. Scand J Infect Dis. 2002;34(5):397-8. 4. Kameh DS, et al. Fatal rhino-orbital-cerebral zygomycosis. South Med J. 1997; 90(11):1133-5. 5. Lemos, et al. Blastomycosis: Organ involvement and etiologic diagnosis. A review of 123 patients from Mississippi. Annals of Diagnostic Pathology. 2000; 4(6):391-406. 6. Smith JA, Kauffman CA. Blastomycosis. Proc Am Thorac Soc. 2010; 7:173-180.

Nothing to Disclose: JWP, LA, GH, TM, FA, CAK, AS, JSS

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm