Question 219

Question:

Three weeks after traveling to California to study desert flowers, a 32-year-old man develops a fever, chest pain, and sore muscles. Two days later, red tender nodules appear on the shins, and the right ankle is painful and tender. An x-ray of the chest shows a left pleural effusion. Which of the following is the most likely diagnosis?

Correct Answer: B.  Coccidioidomycosis

When the USMLE question involves a traveler returning to a trip from a specific locale, it is usually a clue to the diagnosis. In this case, coccidiomycosis is a well-known fungal disease endemic to California, Arizona, New Mexico and Nevada, giving it the moniker “Valley fever.” It usually presents several weeks after exposure as a flu-like illness with fever, myalgias and erythema nodosum over the shins. Patients who fail to clear the infection may progress to chronic pulmonary infection, pulmonary effusions or meningitis.
Blastomycosis and Histoplasmosis are also systemic fungal infections, but the travel history usually involves a recent visit to the Mississippi/Ohio River valley. M. pneuomniae causes a pneumonia syndrome, and M. marinum causes systemic skin nodules, but both are usually opportunistic infections of the immunocompromised.