A 28-year-old man comes to the emergency department due to a cough, malaise, skin rash, and migratory joint pain that began 5 days ago. Two weeks ago, he returned from a hiking trip in the southwestern United States. The patient has a history of ulcerative colitis diagnosed 2 years ago, which has been in remission since infliximab was started 6 months ago. His tuberculin skin testing was negative 7 months ago.
On examination, temperature is 38.3 C (101 F) , blood pressure is 100/70 mm Hg, pulse is 92 /min, and respirations are 14/min. There are several tender, erythematous nodules 2-3 cm in size in both legs over the anterior shins. Oropharyngeal mucosa is dry without any erythema or exudate. On auscultation, fine basal crackles are heard on the left side. There is synovitis and tenderness of both knee joints. The rest of the examination is normal.
Laboratory studies show white blood cells are 16,000/mm³ (72% neutrophils) and platelets are 650,000/mm³. Chest x-ray is unremarkable.
Which of the following is the most likely diagnosis?

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Quizplus · Accepted Answer

This patient's presentation of cough, fever, arthralgia, and erythema nodosum after recent travel to the southwestern United States is consistent with coccidioidomycosis. In immunocompetent hosts, Coccidioides immitis may be asymptomatic or cause only a minor febrile respiratory syndrome ("valley fever"). However, in immunocompromised patients, C immitis can also cause acute pneumonia (most common), chronic progressive pneumonia, nodular or cavitary lung disease, extrapulmonary disease, or meningitis. Patients receiving tumor necrosis factor-alpha inhibitors, such as infliximab, are at increased risk for opportunistic fungal infections. erythema nodosum southwestern United States Diagnosis of coccidioidomycosis is primarily based on epidemiologic (ie, travel) history and clinical findings, and is confirmed with culture, microscopy (potassium hydroxide preparation), or serology. Most patients with valley fever improve without therapy; however, fluconazole or itraconazole should be considered for those with evidence of severe infection or immunosuppression. (Choice B) Hodgkin lymphoma most commonly presents with painless cervical adenopathy. Systemic symptoms may develop as the disorder progresses and adenopathy develops in contiguous areas (eg, mediastinum). This patient does not have lymphadenopathy. (Choice C) Sarcoidosis may present similarly to coccidioidomycosis with cough, fever, joint pain, and erythema nodosum. However, pulmonary involvement is present in >90% of patients with sarcoidosis, and most patients will have abnormal findings on chest x-ray (eg, hilar adenopathy). (Choices D and E) Although tuberculosis and tularemia may have varied presentations, this patient's negative tuberculin skin test, normal chest x-ray, and lack of relevant exposure history (eg, farm exposure or small animal handling for tularemia) make them less likely. Educational objective: Cough, fever, arthritis, and erythema nodosum after recent travel to the southwestern United States is consistent with coccidioidomycosis. Patients receiving tumor necrosis factor-alpha inhibitors are at increased risk for opportunistic infections, including fungal pathogens. __________ References: Update on the diagnosis of pulmonary coccidioidomycosis. (http://www.ncbi.nlm.nih.gov/pubmed/24575994) Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists. (http://www.ncbi.nlm.nih.gov/pubmed/15188373) Opportunistic infections with anti-tumor necrosis factor-a therapy in inflammatory bowel disease: meta-analysis of randomized controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/23649185)

A 28-Year-Old Man Comes to the Emergency Department Due to a Cough