SHM Converge Scientific Abstract ePoster Gallery-Erythema Nodosum and Arthralgias From Diffuse Reticulonodular Coccidioidomycosis

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This case describes a 38-year-old immunocompetent man who presented to a hospital in the northeastern United States with high fevers, bilateral lower-extremity erythematous indurated plaques, and migratory large-joint arthralgias. Because of knee swelling and systemic inflammation, he was initially evaluated for septic arthritis and tick-borne illness. Workup showed leukocytosis, eosinophilia, and elevated CRP/ESR, while broad infectious testing was negative. Dermatology biopsy confirmed erythema nodosum. An initial chest X-ray was read as normal, and he had no respiratory symptoms.<br /><br />Despite empiric doxycycline and ceftriaxone for suspected Lyme disease, fevers persisted. Further review of the chest imaging and a CT scan revealed numerous bilateral pulmonary nodules with ground-glass halos and subcarinal lymphadenopathy, consistent with diffuse reticulonodular lung disease. Only after repeated interviews and family collateral did the patient recall recent travel to Arizona and significant dust exposure near a construction site, a key clue for coccidioidomycosis. Serologic testing was positive for Coccidioides antibody at 1:2 titer. He was started on fluconazole for presumed pulmonary coccidioidomycosis.<br /><br />Over the next two months, follow-up CT imaging showed resolution of the pulmonary nodules and ground-glass changes, with clinical improvement. The case highlights that coccidioidomycosis can present primarily with extrapulmonary immune manifestations such as erythema nodosum and arthralgias, even without respiratory complaints. It also emphasizes the importance of obtaining a detailed travel and exposure history, revisiting the history when the diagnosis remains unclear, and independently reviewing imaging when the initial interpretation does not fit the clinical picture.

Asset Subtitle

Jacob Zinn

Meta Tag

Author List Jacob Zinn, Sean Smith

Category Clinical Vignettes

Concept Coccidioidomycosis

Concept Endemic fungal infection

Concept Arthroconidia

Concept Travel History

Concept Exposure History

Distinguished Non-Finalist

Presenter Organization University of Pennsylvania

Presenting Author Jacob Zinn

Track Adult

Keywords

coccidioidomycosis

erythema nodosum

pulmonary nodules

arthralgias

fever

Arizona travel

dust exposure

fluconazole

ground-glass halos

subcarinal lymphadenopathy

Coccidioidomycosis

Endemic fungal infection

Arthroconidia

Travel History

Exposure History