44 year old white male CC: cough and fever (Quest 139-142 on HM Press Practice Exams)

Patient: 44 year old white male 5'10", 185lbs

Presentation: The patient presents to your office with chief concerns of a cough and fever.  He has had drenching sweats at night that have kept him awake, and with the sweats he has chills that alternate with flushes of heat.  He has chest pain only with the cough, and shortness of breath throughout the day.  He also noticed some painless "warts" on his arms and face, which have spread slowly and grown from 2mm to 10mm in diameter.  The skin lesions started as small eruptions, and now the larger lesions have central healed scarred areas, surrounded with wart-like growths around the outer border.  The cough started about 1 month ago, with the fever and chills.  He first noticed the skin eruptions about 3 weeks ago.  He denies trauma or known environmental exposures or stressors prior to the onset of the illness.

Medical History: Cholecystectomy at age 39.  Men's wellness exam once at age 41; he reports normal findings from that exam.  Surgical repair of broken left ulna after accident at work.

Family History: Mother has osteoarthritis and osteoporosis.  Father has esophageal reflux and BPH.

Social History: He is a construction worker for a Mississippi commercial construction company.  He is single, and spends most of his free time fishing with friends.  He drinks 1 to 2 beers/day usually, but will have up to 6 when he goes fishing.  He does not smoke cigarettes.  He does exercise regularly, and he has a standard North American diet.

Allergies: NKDA

Medications:  Low dose aspirin 81mg QD

Physical Exam: BP 134/82 mmHg. RR 22cpm, HR 72bpm, Temp 101.2F (38.4C).  Chest ausculation reveals bronchial breath sounds, rales, and dullness to percussion diffusely distributed in upper lung fields. Skin examination reveals several 2mm sharply demarcated pink papules on the forearms and face, as well as 3 dusky colored vegetative 2cm plaques, with verrucous, arciform borders.  Two of the plaques are located on the right forearm, and one is on the left side of the face, below the zygomatic arch.  The plaques have central atrophic scarring, and the borders of these lesions are surrounded with 1mm pustules.

1) The most likely diagnosis for his symptoms is ____________ but you must also consider __________ and ___________ in your differentials.
a) Basal cell carcinoma; tuberculosis and aspergillosis
b) Blastomycosis; tuberculosis and histoplasmosis
c) Rocky mountain spotted fever; basal cell carcinoma and small cell lung carcinoma
d) Cryptosporidiosis; coccidiodomycosis and cryptococcosis

2) The most appropriate next step in differentially diagnosing his condition would be
a) Sputum microscopy
b) Lung biopsy
c) Skin biopsy of the plaques
d) Skin biopsy of the papules

3) Which of the following medications would be most appropriate for treating his condition?
a) Doxorubicin 10 mcg IV QD for 14 days
b) Methylphenidate 15mg PO QD for 2 months
c) Diphenhydramine 50mg IM QD for 3 days
d) Itraconazole 200mg PO QD for 6 months

4) Aspirin may interact with alcohol in the following way:
a) Aspirin decreases the hepatotoxicity of alcohol
b) Alcohol decreases the potential risk of gastrointestinal bleeding
c) Alcohol increases the febrifuge effects of aspirin.
d) Alcohol increases the anticoagulation effects of aspirin

Answers:

1) (b) Chest pain, cough, fever and night sweats in a construction worker from Mississippi must make you think of a fungal respiratory infection, and blastomycosis fits the description of the skin lesions as well.  Those wart-like growths are common findings in blastomycosis, and can be helpful in distinguishing this from any other respiratory infection.  TB and histoplasmosis can have similar symptoms.  The skin lesions may look like basal cell carcinoma, but this Dx does not explain the rest of his Sx, and the skin lesions developed much more rapidly than basal cell carcinoma.  Rocky mountain spotted fever presents with pink macules which spread into papules and ecchymoses.  Be sure to distinguish cryptosporidiosis (a parasitic intestinal disease) from cryptocococcosis (a fungal pulmonary or disseminated disease with similar symtoms to this case).

2) (a) Sputum microscopy will demonstrate the fungal infection, with characteristic blastomycosis organisms present; these samples can also be cultured for diagnostic purposes.  A chest X-ray should be performed, which will usually show patchy diffuse infiltrates fanning outward centrally.

3) (d) Itraconazole at a dose of 200mg daily for 6 months is appropriate for the treatment of blastomycosis in most cases.  If the patient has sever respiratory symptoms that could lead to life threatening respiratory distress syndrome, treatment with IV amphotericin B is appropriate.  Doxorubicin is a chemotherapy agent, methylphenidate (Ritilin) is used for ADD and diphenhydramine (Benadryl) is an antihistamine used for allergies or anaphylaxis.



4) (d) Aspirin and alcohol can both cause prolonged bleeding time, and alcohol can exacerbate this effect in patients taking aspirin.

Reference: Beers and Berkow 2006