Justice
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A 65-year-old retired male construction engineer spent 1 month helping to build houses on an Indian reservation in southern Arizona. Six weeks after his return to Georgia, he consults you because of fever, cough productive of minimal sputum, fatigue, and mild dyspnea on exertion. These symptoms have been present for about 3 weeks and are not improving with levofloxacin prescribed by his family physician.
Physical examination is normal. Laboratory studies are normal except for a hematocrit of 35% and an erythrocyte sedimentation rate of 65 mm/h. A chest radiograph shows patchy pulmonary infiltrates in the right middle and right lower lobes.
Which of the following is the most likely diagnosis?
A. Hantavirus pulmonary syndrome
B. Nocardiosis
C. Atypical mycobacterial infection
D. Coccidioidomycosis
E. Ehrlichiosis
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| ganesha123
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D..??
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| dabears2356
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D? patchy infiltrates and refractory to levaquin...so not bacterial infection..
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| liliaeliz
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D BUT HTO. 35 AND ESR 65 CAN BE?
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| cool doctor
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D
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| CocaCola
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d 
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| vecchio
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D desert and not improve by Levoflox
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| Markus2009
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D sounds good
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| Justice
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The correct answer is D
Patients are increasingly presenting with endemic mycoses, such as coccidioidomycosis and histoplasmosis, outside of endemic areas. This increase is related to more frequent travel to areas that are endemic for these fungi and to increased vocational or leisure activities that allow exposure to the organism. Simply residing in or even passing through an endemic area can lead to development of coccidioidomycosis. In contrast, histoplasmosis usually requires participating in an activity related to disruption of the soil or spelunking for aerosolization of the organism and development of subsequent infection. Older adults appear to be at greater risk for developing more serious infection with Coccidioides immitis and are the fastest growing group reported with symptomatic coccidioidomycosis. Recognizing the manifestations of endemic mycoses and taking a complete travel history are essential for diagnosis and appropriate treatment.
Hantavirus pulmonary syndrome is an acute severe pneumonia that occurs mostly among young Native Americans and other residents who are from southwest states adjoining the Four Corners area (Arizona, Colorado, New Mexico, and Utah) and who have come in contact with mice that carry the virus. Nocardiosis occurs mostly in immunocompromised hosts, although it can occur in normal hosts. There is no specific link to the Southwest. Although atypical mycobacterial infections cause pneumonia, findings are usually similar to those of tuberculosis in that they include upper lobe cavitary infiltrates in persons with underlying pulmonary disease or diffuse disease in persons who are
immunocompromised. Finally, pulmonary infiltrates are extremely uncommon in patients with ehrlichiosis.
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