Severe Pulmonary Blastomycosis in a Young Adult: Probable Role of E‐Cigarette Use in Immunosuppression

<b>Background:</b> E-cigarette use has become increasingly prevalent among young adults, raising concerns about its potential health impact and susceptibility to infections. <i>Blastomyces dematitidis</i>, the causative agent of blastomycosis, is a dimorphic fungus endemic to certain regions of the United States. We present a rare presentation of pulmonary blastomycosis in a young, immunocompetent male with chronic e-cigarette use, highlighting the need to consider fungal infections in the differential diagnosis of pneumonia of unknown etiology in patients with risk factors for respiratory illness. <b>Presentation:</b> A 20-year-old male with a 4-year history of daily e-cigarette use and gutter cleaner by occupation presented with a 10-day history of worsening cough, bloody sputum, shortness of breath, night sweats, fever, and weight loss. He was hemodynamically stable, required minimal oxygen support, and was admitted for chest X-ray showing right upper lobe pneumonia and cavitary lesion. The patient was tested for community-acquired pneumonia, atypical pneumonia, granulomatous diseases, and immunosuppressive and viral lymphoproliferative disorders. A diagnostic bronchoscopy ultimately confirmed blastomycosis, leading to treatment with amphotericin B and itraconazole, resulting in significant clinical improvement. <b>Conclusion:</b> Pulmonary blastomycosis often presents asymptomatically, with severe cases more common in the elderly or those with comorbidities and immune dysfunction. Physicians tend to overlook it as a differential diagnosis for primary lung infections, focusing on bacterial pneumonia and tuberculosis in younger individuals. This case underscores the need for further investigation into the impact of e-cigarette use on immune function. This case also highlights the importance of making blastomycosis a reportable disease in Georgia, considering its increasing incidence and the widespread construction and soil disturbance occurring throughout the state.