Case 233: Blastomycosis.

History A 35-year-old man from the upper Midwest region of the United States who had no relevant medical history initially presented to an acute care clinic with multiple small tender skin lesions. His temperature was 38.1°C, and physical examination revealed several small fluctuant masses that were draining purulent material. Skin culture of one of the draining lesions was performed at this time, but there was no subsequent bacterial growth. A diagnosis of furunculosis was made, and Bactrim (sulfamethoxazole-trimethoprim; AR Scientific, Philadelphia, Pa) and a regimen of chlorhexidine washes were prescribed. Two weeks later, the number of skin lesions had increased, and the patient had begun to experience night sweats and fevers. After an episode of hemoptysis and some unusual pain in the patient's right testicle, he presented to the emergency department. At this time, chest radiographs were obtained. The patient was admitted for additional work-up, and computed tomographic (CT) images of the chest were obtained. Physical examination at the time of admission revealed scattered 1-3-cm firm pink hyperpigmented subcutaneous nodules, several of which had overlying pustules. This examination was also notable for a palpable fullness within the right testicle. The patient was afebrile at admission. He denied a history of contact with sick people, illicit drug use, or recent travel. His social history was notable for a 20-pack-year smoking history and a recent relocation to a neighborhood with several new construction sites. Laboratory evaluation revealed leukocytosis (white blood cell count, 15.4 × 10(9)/L; normal range, [3.5-10.5] × 10(9)/L), a chemistry panel revealed a low sodium level (132 mEq/L [132 mmol/L]; normal range, 134-142 mEq/L [134-142 mmol/L]), and serum α-fetoprotein and human chorionic gonadotropin levels were normal. Ultrasonography (US) of the scrotum was performed. Serum analysis was negative for human immunodeficiency virus type 1 and type 2 RNA, and Venereal Disease Research Laboratory and rapid plasma regain test results were negative. Blood cultures were negative for bacterial growth. On the basis of chest CT findings, bronchoscopy with bronchoalveolar lavage was performed. Magnetic resonance (MR) imaging of the abdomen also was performed to further evaluate a focal area of hypoenhancement within the pancreatic tail seen on chest CT images.