ABSTRACT
The lesions shown developed in a 41-year-old nonsmoking man after 5 days of dry cough and fever. About 2 weeks previously, he had been hiking in Arizona. What is the most likely diagnosis?
a. Atherosclerosis obliterans b. Endocarditis c. Histoplasmosis d. Blastomycosis e. Coccidioidomycosis
• Coccidioides immitis is a dimorphic fungus endemic to the southwestern United States
• Valley fever is named after the San Joaquin Valley in California, where the first patients with the clinical syndrome (including fever, cough, fatigue, and weight loss) were identified in 1896
• Travel history is very important to recognizing this condition
• Impaired cellular immunity (such as from steroids, transplantation, human immunodeficiency virus) increases the risk of infection and reactivation of infection, which may have been acquired years previously
• Extrapulmonary manifestations are usually focal. Investigation for them should be prompted by history and physical examination: headache → lumbar puncture, nonhealing ulcers → biopsy, joint effusion → aspiration, skeletal pain → tests for osteomyelitis
• Erythema nodosum, if present, is a good prognostic sign
• Culture, biopsy with silver stains, and serologic testing in appropriate clinical settings are used for diagnosis
• If the patient is immunocompetent, infection is usually selflimited, resolving in weeks to months without treatment
• Reasons for treatment include weight loss of more than 10%, night sweats for longer than 3 weeks, infiltrates in both lungs or more than half of one lung, persistent adenopathy, titers of more than 1:16, lack of development of hypersensitivity antigens, symptoms for longer than 2 months, and persistent absence from work
