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Chest Infections |

Erythema Nodosum and Shortness of Breath in the Sunny Southwest

Yousef Usta*, MD; Wesley Shealey, MD
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St. Joseph Hospital Medical Center, Phoenix, AZ


Chest. 2012;142(4_MeetingAbstracts):272A. doi:10.1378/chest.1357355
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Abstract

SESSION TYPE: Infectious Disease Student/Resident Case Report Posters III

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Erythema nodosum are tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities. Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, viral, bacterial or fungal infections (1).

CASE PRESENTATION: 24 year old, 8 weeks pregnant Mexican American female presents with symptoms of shortness of breath, pleuritic chest pain, productive cough and a new painful rash on her lower extremities of two weeks duration. As an outpatient, patient was found to have a left lower lobe consolidation on chest Xray and was treated with azithromycin. Patient has lived in Phoenix Arizona for the past 17 years. She denies any sick contacts or recent travel. She denies alcohol, tobacco and drug abuse. Sexual history includes her husband only. Past medical history includes latent tuberculosis treated with nine months of isoniazide one year ago. Throughout her stay, patient was afebrile and had no leukoctosis. Sputum and blood cultures were negative. Urine strep antigen, viral cultures, infuenza, and rapid strep antigen detection test were negative. Coccidioidomycosis IgM and IgG serologies were positive. Skin biopsy was consistent for erythema nodosum. She was started on IV fluconazole, and her symptoms of shortness of breath, chest pain, and rash all subsided within a few days.

DISCUSSION: Coccidioides immitis is endemic in certain parts of the desert south west region. It is a fungus that resides in the soil that breaks off into airborne spores. Infection is caused by inhalation of the particles and is not transmitted from person to person. Serious complications include severe pneumonia, lung nodules, and disseminated disease. The disseminated form of valley fever can devastate almost any organ in the body, causing skin ulcers, abscesses, bone lesions, meningitis, and often death(2). Coccidioidomycosis during pregnancy is a serious illness for which high rates of mortality have been reported in many studies. It has been associated with a greater likelihood of extra-pulmonary dissemination and more serious outcomes. Although when erythema nodosum was present, outcomes were more favorable(3).

CONCLUSIONS: Diagnosing the precipitating source of erythema nodosum may be quite challenging. Having a broad differential diagnosis for erythema nodosum will avoid missing rare and life threatening infections. Keeping coccidioidomycosis as a differential in almost all infectious workups in the desert south west will help clinicians not miss this commonly seen “Valley Fever.”

1) Schwartz RA, Nervi SJ. Erythema nodosum: a sign of systemic disease. Am Fam Physician. 2007 Mar 1;75(5):695-700.

2) Stevens DA. Coccidioidomycosis. N Engl J Med. 1995 Apr 20;332(16):1077-82

3) Arsura EL, Kilgore WB, Ratnayake SN. Erythema nodosum in pregnant patients with coccidioidomycosis. Clin Infect Dis. 1998 Nov;27(5):1201-3.

DISCLOSURE: The following authors have nothing to disclose: Yousef Usta, Wesley Shealey

No Product/Research Disclosure Information

St. Joseph Hospital Medical Center, Phoenix, AZ

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