Question

A 48-year-old male farmer from Arkansas presents with a 6-week history of a slowly enlarging paranasal skin lesion, 10-pound weight loss, low-grade fever, and a nonproductive cough. He has no underlying medical illness. On examination he has a

6 x 4-cm right paranasal verrucous lesion that has a heaped-up, warty appearance with a violaceous hue. There is an area of central healing. A chest radiograph reveals a 5 x 4-cm right parahilar noncavitary mass lesion. You must explain ALL options.

What is the most likely diagnosis?

A. Squamous cell carcinoma

B. Histoplasmosis

C. Blastomycosis

Tuberculosis

Nocardiosis

A presumptive diagnosis in this patient can best be made through which of the

following?

Fungal serology

Blood cultures

Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy

Bacterial, fungal and mycobacterial cultures of the skin lesion

Skin biopsy with special stains for fungi and acid-fast bacilli

Which therapy should be initiated in this patient?

Isoniazid, rifampin, and pyrazinamide

Itraconazole

Amphotericin B

Sulfisoxazole

Radiation therapy to the paranasal and lung lesion

Answer 1

In my view the most probable diagnosis of the patient is Nocaridosis .

Nocardiosis is a gram positive , acid fast bacilli , that may cause accidental infection .

Most commonly it is seen in outdoor workers like farmers.

Squamous cell carcinoma could also be the diagnosis, but it doesn't cause pulmonary lesions.

Tuberculosis is also not possible because the person has non productive cough .

Both histoplasmosis and blastomyosis doesn't cause any skin lesions .

Nocardia, causes both pulmonary and extra pulmonary lesions , so my best guess will be Nocardiosis .

Lab diagnosis -

• Bronchoscopy
• Brain / skin / lung biopsy
• Sputum Culture .

Treatment -

Sulfimoxazole or high doses of sulgonamides . If the patients doesn't respond well to sulfonamides , ampicillin or erythromycin can also be started .