A young man evaluated for suspicion of lymphoma.

A 21-year-old man had moved to Riverside County, California from Botswana at 7 years of age. He presented with B symptoms: intermittent fever, fatigue, and 20 kg weight loss progressive over 6 weeks. He had no relevant past medical history; his last trip to Africa was in 2002. On examination, he had axillary and inguinal lymphadenopathy; nodular skin ulcerations were present on the forehead, fingers, scalp, and chest (Figure 1C). Laboratory studies showed low hemoglobin (10.7 g/dL), a negative Mycobacterium tuberculosis interferon-γ release assay, and a negative serology for human immunodeficiency virus. A concern for lymphoma prompted a positron emission computer tomography scan (PET CT-coronal images shown), which showed extensive tracer uptake in mediastinal and axillary lymph nodes (Figure 1A-anterior coronal image shown), vertebral bodies and pedicles, and the right testis (Figure 1B-posterior coronal image shown).1 An excisional biopsy (hematoxylin and eosin [H&E] stain) of a left axillary lymph node showed spherules consistent with Coccidioides species (Figure 1D). The serum Coccidioides complement fixation titer was 1:512; cerebrospinal fluid analysis was unremarkable. Fluconazole 800 mg/d by mouth led to clinical resolution. Infections with Coccidioides immitis/posadasii are common in the southwestern United States, Mexico, and parts of South America,2 and has recently been found to be expanding in range to previously unsuspected areas such as Washington State.3

Figure 1.

(A and B) Positron emission tomography. (A) Coronal section-anterior view; (B) coronal section-posterior view) of patient with coccidioidomycosis; noted tracer uptake in axillary and mediastinal lymph nodes, cervical and lumbar vertebrae, left ilium, and perineum. (C) Integumenal lesions on patient's anterior chest. (D) Hematoxylin and eosin (H&E) stain of left axillary lymph node biopsy showing Coccidioides spp. spherules within a granuloma.