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 negativeMycobacterium tuberculosis interferon-g 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). 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 *Address correspondence to Anthony P. Cannella, 9500 Gilman Drive, Mail Code 0741, Palade Laboratories, Rm 125, San Diego, CA 92093-0741. E-mail: [email protected] 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.