PGY3 Jared Geibig presented a case of a 39 y/o M with history of HTN, HLD and ESRD s/p renal transplant (2016 in El Salvador) presents with 2 months of fever, chills, cough and fatigue. He was previously diagnosed with pneumonia and did not improve with a trial of antibiotics. Now over the past 203 weeks, he has had persistent night sweats, loss of appetite and 23 pound weight loss. He has also noticed red swollen patches on his shins/ankles and wrists/forearms. Patient also reports 2 weeks of pain in b/l wrists and L ankle, 8/10, worsened at night and with movement, not improved with medications. Medications include mycophenolate 500mg BID and Tacrolimus 1mg BID. He was born in El Salvador and moved to the US 17 years ago and now lives in Utah with family. He works in a factory making toilets. He is former tobacco use (1 ppd x8 years), past alcohol use and denies any drug use.
Vitals: T 36.6, HR 119, RR 20, BP 145/112, O2 sat 97% RA
Physical Exam significant for regular cardiac and pulm exam, tender and erythematous nodules over the b/l wrist, hand and anterior lower extremities. There is pain with deep flexion of L wrist, increase swelling in L wrist. TTP in R elbow and wrist, no overt swelling. NO pain with ROM of b/l knees and ankles.
CBC: WBC 12.2> Hb 16/Hct 49 <Plt 326
Diff: 82% PMN, 6.7% lymph, 9% monocytes, 1.6% eosinophils, and 0.6% basophils
Na 132/K 4.7/Cl 99/HCO3 16/BUN 31/Cr 2.27 <Glucose 113
ALP 120>T.protein 7.4/Albumin 4/AST 22/ALT 26/Tbili 0.3/Dbili <0.2
Coags: PT 13.1, INR 1.01
CXR with focal consolidation in the R upper lobe
CT Thorax showed RUL consolidation with an area of internal cavitation, measuring up to 3.1cm.
- BCx negative x2
- Lactate 0.9
- CRP 105.2 mg/L (normal <4.9)
- Acute hepatitis panel
- Hep A IgM negative
- Hep B core IgM negative
- Hep B surface Ag negative
- Hep C Ab: negative
- HIV non-reactive
- RPR non-reactive
- GC/CT negative
- HSV 1/2: negative
- Flu/RSV negative
- ASO negative
- AFB negative x3 and MTB PCR negative x2
- Respiratory culture 2+ oral flora
- Fungal BCx negative
- Serum Aspergillus Ag negative
- Brucella IgM and IgG negative
- Urine histo negative
- Serum crypto Ag negative
- PCP DFA negative
- Cocci Ab Serum 1:4
- Cocci Ab CSF <1:1
- UA with >300 protein, neg leuk/nitrites
- FeNa: 3.8%, FeUrea 54.5%
- Uprotein/Cr 4.11
- Tacrolimus 12.3 ng/mL
- ANA negative
- ANCA negative
- XR hand, wrist, knee and ankle negative
Derm biopsy revealed findings consistent with coccidiomycosis.
Treatment: Patient started on Fluconazole and was discharged with follow up with his Utah PMD.
Take home points:
- Cavitary lesions differential diagnosis: Tuberculosis, Cocci, Sarcoidosis, invasive molds (mucor)
- Erythema nodosum: delayed type hypersensitivity. Generally self-resolves.
- In Southern California, when a patient presents with erythema nodosum, two differentials is on top: Tuberculosis and Cocci. Sarcoidosis is another.
- Other differentials: Infection (Strep pharyngitis is most common cause nation wide), drugs (antibiotics), IBD
- Please keep in mind that the azole medications can interfere with tacrolimus and should monitor the levels closely with transplant nephrology.