A 35-year-old male from Wisconsin presents to his physician complaining of fever, night sweats, productive cough, and an unintentional 17-lb weight loss over the past 3 months. Several days ago, he also began to notice multiple skin lesions. He has no known medical problems and does not take any medications, nor does he use tobacco, alcohol or illicit drugs. He works outdoors in wood cutting and construction. Physical examination reveals a man of medium build in no apparent distress. His temperature is 38.4°C (101.1°F), blood pressure is 120/68 mm Hg, pulse is 86/min, and respirations are 14/min. Skin examination reveals multiple, well-circumscribed, verrucous, crusted lesions. Chest x-ray shows left upper lobe consolidation and two lytic lesions in the anterior ribs. Which of the following is the most likely cause of his current symptoms?

Question

A 35-year-old male from Wisconsin presents to his physician complaining of fever, night sweats, productive cough, and an unintentional 17-lb weight loss over the past 3 months.  Several days ago, he also began to notice multiple skin lesions.  He has no known medical problems and does not take any medications, nor does he use tobacco, alcohol or illicit drugs.  He works outdoors in wood cutting and construction.  Physical examination reveals a man of medium build in no apparent distress.  His temperature is 38.4°C (101.1°F), blood pressure is 120/68 mm Hg, pulse is 86/min, and respirations are 14/min.  Skin examination reveals multiple, well-circumscribed, verrucous, crusted lesions.  Chest x-ray shows left upper lobe consolidation and two lytic lesions in the anterior ribs.  Which of the following is the most likely cause of his current symptoms?

Quizplus · Accepted Answer

A 3-month history of low-grade fever, night sweats, productive cough, and weight loss could be explained by chronic infection, malignancy, or rheumatologic disease. In this particular patient, the skin involvement, lytic bone lesions, and geographic location make Blastomycosis (Choice D) the most likely cause of his illness. Blastomycosis is a fungal infection that occurs most often in the vicinity of the Great Lakes, Mississippi river and Ohio River basins (Wisconsin has the highest infection rate). The pulmonary symptoms and chest x-ray findings of Blastomycosis may resemble tuberculosis and histoplasmosis. However, systemic Blastomycosis may cause characteristic ulcerated skin lesions and lytic bone lesions. (Choice A) Reactivation tuberculosis (Tb) could explain this patient's systemic symptoms and upper lobe infiltrate. Disseminated Tb may affect many organs and tissues including the peritoneum, cervical lymph nodes, eyes, bones, and skin. Risk factors for Tb include homelessness, alcohol use disorder, immunosuppression, and work in the healthcare field. This patient's lack of risk factors makes this diagnosis less likely. (Choice B) Sarcoidosis is a rheumatologic disease which may present with fever, cough, weight loss, and arthritis. Chest x-ray typically reveals bilateral hilar adenopathy with interstitial infiltrates. Erythema nodosum, tender red nodules on the shins, are the typical skin manifestation. Bone lesions are not expected. (Choice C) Osteosarcoma is a rare cancer that mainly affects adolescents. The distal femur is the region most often affected, and patients will present with a soft tissue mass and localized pain. Systemic symptoms like fever and weight loss are generally absent. Skin lesions are not expected. (Choice E) Coccidioidomycosis is a fungal infection of the lungs that can cause fever, cough, and night sweats. Extrapulmonary manifestations may involve the skin, meninges, and skeleton. Coccidioidomycosis is endemic to the southwestern United States, not Wisconsin. Educational objective: Blastomycosis is a pulmonary fungal infection endemic to the Great Lakes, and Mississippi and Ohio River basins. Systemic Blastomycosis may cause skin and bone lesions in addition to pulmonary manifestations. Broad-based budding yeast grown from the sputum confirm the diagnosis. Itraconazole or amphotericin B may be used to treat symptomatic disease.

A 35-Year-Old Male from Wisconsin Presents to His Physician Complaining