Abstract Fungal respiratory infections pose substantial diagnostic challenges, particularly when they mimic bacterial pneumonia. Fusarium species are ubiquitous environmental molds that typically infect profoundly immunocompromised individuals, such as those with hematologic malignancies, neutropenia, or post-transplant immunosuppression. Pulmonary Fusarium infection in a relatively immunocompetent host is exceedingly rare. We present a case of Fusarium pneumonia in a middle-aged man with end-stage renal disease (ESRD) on hemodialysis and no overt immunosuppression, whose persistent respiratory symptoms and radiologic progression despite appropriate antibacterial therapy revealed an uncommon fungal etiology. A 47-year-old man with ESRD, asthma, hypertension, and recent community-acquired pneumonia due to Streptococcus viridans presented with worsening dyspnea, cough, and low-grade fever shortly after completing antibiotic therapy. On admission, he was febrile with oxygen saturation of 89% on room air. Chest CT revealed new left-sided opacities and mediastinal lymphadenopathy, with partial improvement of prior infiltrates. Empiric therapy for hospital-acquired pneumonia with intravenous cefepime was initiated. Despite appropriate antibacterial coverage, he experienced persistent cough, fatigue, and intermittent hemoptysis. Repeat imaging demonstrated progressive bilateral infiltrates and small pleural effusions. Negative viral and MRSA studies prompted pulmonary and infectious disease consultation. Repeat respiratory cultures identified Fusarium species, leading to discontinuation of antibacterial therapy and initiation of intravenous liposomal amphotericin B and voriconazole. Bronchoscopy with bronchoalveolar lavage (BAL) was performed to evaluate for dissemination; cytology was negative, and fungal cultures from BAL remained sterile at discharge. He tolerated antifungal therapy well with careful renal and hepatic monitoring. After one week of treatment, repeat CT demonstrated marked radiologic improvement, and his oxygen requirement resolved. He completed a two-week intravenous antifungal course followed by a four-week oral voriconazole regimen. At discharge, he was afebrile, ambulatory, and maintained normal oxygen saturation on room air.This case highlights the diagnostic complexity of Fusarium pneumonia in non-neutropenic hosts and shows the importance of maintaining a broad differential when evaluating nonresolving pulmonary infiltrates. While Fusarium is known for its angioinvasive and drug-resistant behavior, early identification and initiation of dual antifungal therapy can be lifesaving. Chronic kidney disease and hemodialysis may confer relative immune dysfunction, predisposing such patients to opportunistic fungal infection even without overt immunosuppression. Persistent or worsening pulmonary findings despite broad-spectrum antibiotics should prompt reconsideration of fungal or atypical etiologies. Multidisciplinary collaboration and early culture-directed management remain essential for successful outcomes in these rare but potentially fatal infections. This abstract is funded by: None
Chaney et al. (Fri,) studied this question.