On February, 2011, a previous healthy man was admitted to a local hospital with cough with sputum for 1 month. He had lived in America (Tenessee) on business for two years from 2007 to 2009. Chest plain radiograph showed a consolidation on right upper lobe.

Chest CT and Percutaneous transthoracic needle aspiration biopsy was done.

The biopsy result was chronic granulomatous inflammation, but AFB stain was negative.

He was diagnosed with pulmonary tuberculosis and started on anti-tuberculous medication . However he did not improve on anti-TB medication for two months. He even drained pus from the skin where transthoracic biopsy was done through. Chest plain radiograph and CT findings were compatible with empyema. Finally, he was recommended for resection of the right upper lung and transferred to this hospital on May 9, 2011. On June 9, 2011, He underwent Right upper lobe lobectomy, En bloc RML wedge resection and Pus sac evacuation. The biopsy showed chronic granulomatous inflammation with many multinucleated giant cells. PAS, GMS and Fontana Masson stain showed highlighting yeast form fungal organism.

Initial vital sign – BP 110/760 mmHg, BT 36.0℃, PR 84 bpm.

Pus drained from the previous biopsy site.

Decrease breathing sound on Rt. upper lung field

The CBC revealed 13650 (Neutrophil segmented 71%) >12<451000.

The ESR was 120 mm/h and CRP 6.88 mg/dl. The level of AST/ALT was 16/8 IU/L and BUN/Cr was 15.2/0.76 mg/dl.

BAL fluid AGB stain (-) , culture (-) ,MTB PCR (-) galactomannan 0.33

After the diagnosis of blastomycosis, we began to treat the patient with itraconazole syrup on June 201. Currently, he’s been on anti-fungal treatment with itraconazole for 4 months and asymptomatic. The last chest plain radiograph showed no new infiltration.