Review Question - QID 108606

This patient has fatigue, weight loss, dry cough, diffuse arthralgias, peripheral eosinophilia, and a nodule seen on chest radiograph with recent travel to the southwestern United States, most consistent with disseminated coccidiomycosis. This disease can also present with erythema nodosum.

Coccidiomycosis is a dimorphic fungus that is endemic to states such as Arizona, California, New Mexico, as well as Central and South America. The fungus resides in soil and is spread by windstorms and earthquakes. Infection is often self-limited and asymptomatic or isolated to pulmonary symptoms, but dissemination can cause the constellation of symptoms known as “desert rheumatism” or “valley fever”. The classic triad of symptoms includes fever, arthralgias, and skin rash (erythema nodosum or multiforme). This disease can be diagnosed with detection of immunoglobulin M (IgM) in serum, detection of antigen in serum, and tissue biopsy showing spherules that are filled with endospores. Treatment is with amphotericin B for systemic infections and itraconazole or fluconazole for localized infections.

Figure/Illustration A shows a chest radiograph with a solitary pulmonary nodule in the right upper lung zone (red circle). This is a common finding in patients with coccidiomycosis.

McAninch et al. present a case of an immunocompromised patient who developed systemic disseminated coccidiomycosis. They discuss how hematogenous spread of the organisms is the likely mechanism for spread of the disease. They recommend having a high index of suspicion for atypical organisms such as this in immunocompromised patients.

Incorrect Answers:
Answer 2: Hypertrophic pulmonary osteoarthropathy is a periosteal reaction seen in lung cancer, other chronic hypoxemic diseases, and less commonly inflammatory bowel disease. It can present with digital clubbing and arthritis of the distal interphalangeal joints and should prompt evaluation for pulmonary malignancy if no other cause is clear. This patient is at risk for lung cancer due to her long smoking history and pulmonary nodule on radiograph, but her extrapulmonary symptoms suggest that another cause is more likely.

Answer 3: Malar rash is most commonly seen in lupus. This patient is the right demographic for lupus and has joint pains and systemic symptoms that may fit the diagnostic criteria (SOAP BRAIN MD – Serositis, Oral ulcers, Arthritis, Photosensitivity, Blood disorders, Renal involvement, ANA, Immunologic markers dsDNA and anti-Smith, Neurologic symptoms, Malar and Discoid rash). Lupus flares can be treated with steroids. This patient’s recent travel and her lab findings favor coccidiomycosis.

Answer 4: Oral thrush from Candida is commonly associated with HIV/AIDS and inhaled corticosteroids. It is distinguished from leukoplakia in its ability to be scraped off the tongue. It can be treated with oral fluconazole or nystatin. This patient’s constitutional symptoms and sexual practices make HIV a possibility, but her pulmonary symptoms and her recent travel to the southwest make coccidiomycosis a more compelling diagnosis.

Answer 5: Tender gray pustules on the palms and soles are seen in disseminated gonococcal infection. Known as “tenosynovitis-dermatitis syndrome,” patients may have diffuse arthritis in addition to the skin findings. Diagnosis is by blood, oral, or cervical/urethral cultures, and treatment includes ceftriaxone. This patient’s sexual history and joint pain do put her at risk for gonococcemia, but her pulmonary symptoms and lymphocytosis/eosinophilia (as opposed to neutrophilic leukocytosis) make this diagnosis less likely.

Bullet Summary:
Coccidioidomycosis may present with pulmonary findings with or without constitutional symptoms such as erythema multiforme, erythema nodosum, and arthralgias.