Pulmonary Infiltrates, Eosinophilia, and a Facial Skin Nodule
A21-year-old black man, a nonsmoker previously in good health, presented to the Letterman Army Medical Center Pulmonary Service after six weeks of nonproductive cough, headaches, fevers, anorexia, and a 4.5 kg (ten pound) weight loss. He denied dyspnea, hemoptysis, chest pain, high risk behavior for human immunodeficiency virus (HIV) infection, or gastrointestinal symptoms. He lived and worked in northern California with recent travel to Korea. He had received a ten-day course of erythromycin without relief of his symptoms.
Physical examination revealed a well-developed black man in no apparent distress, with a blood pressure of 124/72 mm Hg, a pulse of 80 beats per minute, a temperature of 40.5°C, and respirations of 14 per minute. Chest examination was clear to per-cussion and auscultation. Cardiac examination re-vealed a grade 3/6 systolic ejection murmur at the lower left sternal border. There was no hepatosple- nomegaly. Genitourinary examination was normal. Shotty, nontender lymphadenopathy was present in his left posterior cervical chain. Skin examination revealed a 1 x 2-cm soft, nontender, mildly erythe-matous nodular lesion at the right temporal region (Fig 1). The remainder of the examination was normal. cialis soft tabs
Laboratory examination showed a hematocrit value of 41 percent, platelet count of 833 x lOVL, and white blood cell count of 17.7xl09/L with 48 percent segmented neutrophils, 3 percent band cells, 24 percent lymphocytes, and 25 percent eosinophils. Arterial blood gas on room air showed pH 7.43, Pco2 of 5.0 к Pa (38.1 mm Hg), and Po2 of 11.9 kPa (89.7 mm Hg). Results from serum chemistries and urinalysis were normal.
Chest roentgenogram showed left perihilar lymphadenopathy and bilateral alveolar nodular infiltrates predominately in the lingula (Fig 2).
A diagnostic skin biopsy was performed. What is the likely diagnosis?
(a) Sarcoidosis
(b) Churg-Strauss syndrome
(c) Lofflers syndrome
(d) Coccidioidomycosis
(e) Tropical filiarial eosinophilia
Answer: (d) Disseminated coccidioidomycosis
Biopsy of the temporal skin lesion demonstrated small, noncaseating granulomas with microabscesses, and an eosinophilic infiltrate without organisms. Cul¬tures of the lesion subsequently grew Coccidioides immitis.
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Patients with sarcoidosis may also have skin nodules, papules, and plaques, but eosinophilia is usually not seen. The chest roentgenogram can show a variety of abnormalities, but symmetrical bilateral hilar and paratracheal lymphadenopathy is classic. Churg- Strauss syndrome comprises the triad of eosinophilia, pulmonary infiltrates, and airflow obstruction. The skin manifestation is a palpable purpuric skin eruption caused by vasculitis. Lofflers syndrome, usually caused by parasites, drugs, and environmental agents, is characterized by peripheral eosinophilia and eosinophilic pulmonary infiltrates. It can be associated with skin lesions, as in cutaneous larva migrans. Tropical filarial eosinophilia, due to Wuchereria bancrofti and Brugia malayi, causes extreme eosinophilia. Lym¬phatic tracts may become inflamed, and abscesses can form, but not other skin lesions are usually seen.
