Blastomycosis Infection in The Setting of Immunosuppression with Concurrent Methotrexate and Adalimumab for Treatment of Psoriasis

Blastomycosis is a dimorphic fungi endemic to the Ohio/Mississippi Rivers and the Great Lakes that can infect immunocompetent and immunosuppressed individuals. Systemic fungal infections, such as histoplasmosis or blastomycosis, have often been reported in patients taking TNF-α inhibitors such as adalimumab. However, blastomycosis is significantly less common than histoplasmosis and no cases have been described in the literature. We report a case of systemic blastomycosis associated with adalimumab and methotrexate use for psoriasis and psoriatic arthritis treatment that required extensive treatment and discontinuation of both medications. To our knowledge, this is the first case of systemic blastomycosis associated with adalimumab and methotrexate treatment for psoriasis to be described in the literature.