November 2019 Imaging Case of the Month: A 56-Year-Old Woman with a Rash

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 56-year-old post-menopausal woman with a remote history of asthma and asymptomatic uterine fibroids presented with a macular-papular rash over the upper chest, upper medial left forearm, and medial legs, without scaling that has intermittently recurred over the previous few years. The rash is unaccompanied by fever, chills, rigors, abdominal pain, cough, conjunctivitis, urethritis, or any other mucocutaneous lesions. The patient did not note any seasonal relationships or association with food, and the rash regresses promptly with H₁ or H₂-blocker therapy.

The patient’s past medical history was otherwise unremarkable. Her surgical history was positive only for a laparoscopic left inguinal hernia repair 7 years earlier. The patient indicated she was neither a smoker nor a drinker. Her medications included an as-needed albuterol inhaler, a steroid inhaler, a nasal steroid spray, a multivitamin, and a topical steroid.

The patient’s physical examination showed normal vital signs, although her pulse rate was 95 beats / minute. The physical examination was otherwise entirely within normal limits aside from her presenting complaint of rash; in particular, her lungs were clear to auscultation. 

About 2 weeks later, the patient began to complain of myalgias and some wheezing in addition to her rash, with some mild fatigue as well. She denied other complaints, such as coryza, cough, nasal drainage, ear pain, and neck pain or stiffness. At repeat physical examination, her lungs remained clear to auscultation; no wheezing was noted. A dermatology consult suggested that the rash was most consistent with atopic dermatitis, for which a topical steroid was prescribed.

Basic laboratory data showed a white blood cell count in the normal range, mild anemia (hemoglobin / hematocrit = 11.5 mg/dL / 34.7%), a normal platelet count, normal serum chemistries and renal function parameters, and normal liver function tests aside from a mildly elevated alkaline phosphatase level of 145  U/L147 (normal, 35 – 104 U/L). A C-reactive protein level was elevated at 38.5 mg/L (normal, ≤8 mg/L). The patient was referred for chest radiography (Figure 1).

Figure 1.  Frontal chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to be directed to the second of twelve pages)

1. The chest radiograph shows mediastinal and peribronchial lymph node enlargement
2. The chest radiograph shows bilateral consolidation
3. The chest radiograph shows cavitary lung disease
4. The chest radiograph shows findings suggesting increased pressure pulmonary edema
5. The chest radiograph shows numerous small nodules

Cite as: Gotway MB. November 2019 imaging case of the month: a 56-year-old woman with a rash. Southwest J Pulm Crit Care. 2019;19(5):127-43. doi: https://doi.org/10.13175/swjpcc065-19 PDF 

Medical Image of the Week: Cutaneous Coccidioidomycosis

Figure 1. Right distal anterior thigh. Fungal culture grew Coccidioides immitis from biopsy.

A 46-year-old Hispanic man with no known past medical history presents to his primary care physician for a progressively worsening “rash” located over his right thigh. Patient described the lesion as raised, scaly, and itchy. It has been “growing” for the past one year and started out as a small “pimple”. Patient denied any trauma to the effected region over this time period. Surgical history was significant for a splenectomy 15 years prior that was needed after a traumatic accident. He works in construction and lives in southern Arizona. He denied alcohol, tobacco and or illicit drug use. Patient has attempted to treat this skin lesion with over the counter hydrocortisone ointment with no relief. He denied any other associated symptoms including fever/chills, headache, vision changes, night sweats, weight loss, cough, shortness of breath, and or joint pains. Vital signs were stable upon presentation. Physical exam was entirely benign other than the isolated skin lesion shown above (Figure 1). It measured roughly 5cm at its greatest dimension and was located just superior the right knee on the anterior portion of the distal thigh. Nodularity was appreciated upon palpation but no tenderness was noted. Areas of erythema were non-blanching. Small satellite lesions were seen on the perimeter.

He was sent to a dermatologist and biopsies were performed. Light microscopy and culture confirmed the diagnosis of cutaneous coccidioidomycosis. Initial laboratory work revealed a normal complete blood count and complete metabolic panel. Serum coccidioides IgM antibody was negative but IgG was confirmed to be positive with a reflex complement fixation titer of 1:16. Chest X-ray was normal. Patient was started on oral fluconazole 400mg daily. Repeat coccidioides IgG titers decreased to 1:8 at a four- week follow-up. Patient has been tolerating the medication well and skin lesion has begun to regress.

Norman Beatty MD¹ and Mayar Al Mohajer MD²

¹Departments of Internal Medicine and ²Infectious Diseases

University of Arizona College of Medicine

Tucson, AZ

Cite as: Beatty N, Al Mohajer M. Medical image of the week: cutaenous coccidioidomycosis. Southwest J Pulm Crit Care. 2015;11(5):226-7. doi: http://dx.doi.org/10.13175/swjpcc110-15 PDF

Medial Image of the Week: Palmar Erythema Multiforme

Figure 1. Palmar rash in a patient with acute pulmonary coccidioidomycosis resembling erythema multiforme.

An 18 year-old male presented for evaluation of abnormal chest imaging. Prior to moving to Tucson, Arizona three weeks before presentation, he was diagnosed with ankylosing spondylitis and was started on adalimumab (Humira). Approximately one week prior to presentation he developed a fever and cough. Over 3-4 days the cough worsened and he developed a palmar rash (Figure 1). He was seen in the emergency department and was started on levofloxacin. Prior to presentation in the pulmonary clinic his rash had resolved but the cough had persisted. Chest imaging showed airspace opacities within the left upper lobe with associated small left pleural effusion. Bronchoalveolar lavage revealed 57% eosinophils. Fungal cultures, bacterial cultures, and cytology were non-diagnostic. Coccidioides IgG antibody was negative but Coccidioides IgM antibody converted to positive, suggesting acute infection. The patient was started on oral fluconazole and clinically improved. Erythema nodosum and erythema multiforme are noted in as many as 25 % of patients with acute pulmonary coccidioidomycosis. The rashes usually occur within a few days of infection and are considered a good prognostic sign (1).

Ryan Nahapetian, MD, MPH and Joshua Malo, MD

Pulmonary, Allergy, Critical Care, & Sleep Medicine

University of Arizona, Tucson, AZ

Reference

1. Smith JA, Riddell J 4th, Kauffman CA. Cutaneous manifestations of endemic mycoses. Curr Infect Dis Rep. 2013;15(5):440-9. [CrossRef] [PubMed]

Cite as: Nahapetian R, Malo J. Medical image of the week: palmar erythema multiforme. Southwest J Pulm Crit Care. 2015;11(5):217. doi: http://dx.doi.org/10.13175/swjpcc102-15 PDF