A 50-Year-Old Man Comes to the Physician Because of a Non-Healing

A 50-year-old man comes to the physician because of a non-healing skin lesion on his right thigh.  The lesion first appeared as a boil; however, it increased in size over the last one month and has started draining purulent material.  There is no history of trauma or insect bites.  He also complains of malaise and constant right foot pain that improves with ibuprofen.  Three months ago, he was treated for community-acquired pneumonia with 7 days of antibiotics and his symptoms have somewhat improved.  He still has an occasional productive cough.  He also thinks he might have lost some weight.  He has no history of asthma or respiratory disease.  His current medications include metformin, glipizide, and sitagliptin for diabetes, and rosuvastatin for hyperlipidemia.  He is a lifetime non-smoker.  He lives in upstate New York and often visits his friends in Long Island and Connecticut.  He travels to Mississippi once or twice a year to visit his daughter.
His temperature is 37.8 C (100 F) , blood pressure is 124/84 mm Hg, pulse is 96/min, and respirations are 18/min.  Rales are heard over the right upper lung lobe.  There are no heart murmurs.  The abdomen is soft and no organomegaly is appreciated.  Right foot examination reveals exquisite tenderness in the lateral midfoot.  Skin examination shows a 2 x 2 cm beefy red granulomatous plaque with mild creamy exudate.
Foot CT scan reveals two lytic lesions and a large focal cyst in the mid foot.  Chest imaging shows patchy alveolar opacities involving the right upper lung lobe; there is no hilar lymphadenopathy.
Which of the following is the most likely diagnosis?

A) Actinomycosis
B) Blastomycosis
C) Histoplasmosis
D) Mycobacterial infection
E) Nocardiosis