A 40-year-old black man was referred to pulmonary clinic for evaluation of pulmonary nodules. He reported a recent one time incident of right lower quadrant abdominal pain for which he was seen in the ED where an abdominal CT scan and a chest radiograph revealed a right lower lobe lung nodular opacity. On further review of systems, he reported occasional right-sided pleuritic chest pain, mild malaise, mild exertional dyspnea, and extensive nonpruritic skin rash on his left shin that had developed about 3 months before his current presentation. The rash had worsened despite the efforts of his primary care providers to treat it. He denied cough, fever, chills, night sweats, hemoptysis, arthralgias, or weight loss. Additional medical problems included poorly controlled hypertension. His family history was significant for diabetes in his mother and two siblings, chronic anemia in his sister, and lung cancer in his uncle. He lived in northwest Louisiana and worked as a roofer most of his adult life but had recently worked in landscaping. No significant environmental exposure to chemicals, dust, or asbestos was indicated. He reported a 15 pack-year smoking history, but no alcohol or illicit drugs. Six years before his current presentation, he was incarcerated for a period of 8 months. He also reported sexual activity with a male partner in the past but no recent sexual activity.