Methods
Initial laboratory investigations showed mild leukocytosis at 10.82
K/uL(normal range: 4.23-9.07 K/uL), elevated ESR at 78 mm/hr., elevated
CRP at 19.2 mg/dl, and normal C3 and C4 levels. Hepatitis viral panel,
HIV, and syphilis were non-reactive. PCR for respiratory viral infection
and Neisseria and Chlamydia were all negative. A CT chest revealed a 1.5
cm spiculated nodule present in the posterior right lower lobe
surrounded by ground-glass attenuation with an enlarged right hilar
lymph node and a few sub-centimeter nodules in the right lower lobe (Fig
2.1). A CT-guided tissue biopsy of the peripheral lung nodule was
performed for definitive diagnosis. Additionally, skin biopsies of the
cutaneous manifestations were done. While anticipating the biopsy
results, the patient’s rashes and painful swollen ankles gradually
resolved on their own.
The pathological report of the lung biopsy demonstrated granulomatous
inflammation with multinucleated giant cells and was negative for
malignancy, raising suspicion for inflammatory processes which included
fungal infection, tuberculosis, and sarcoidosis (Fig 3.1-3.2). The
immunohistochemistry stains for CD68 highlighted histiocytes, and CK7
showed lung parenchyma around granulomas. GMS was negative for fungal
infection and AFB was negative for mycobacteria (Fig 4). The skin
biopsies showed significant papillary dermal edema with a mixed
inflammatory infiltrate composed of lymphocytes and neutrophils, and
direct immunofluorescence studies were all negative, consistent with
Sweet’s syndrome.
Additional laboratory investigations including QuantiFERON TB,
Aspergillus, Histoplasma, Blastomyces, Thermoactinomyces spp. ,
Saccharoplyspora rectivir, and Saccharomonospora viridis later returned
negative. Coccidioides Ab Complement Fixation (CF) was positive with a
titer of 1:16, yeast phase Ab titer of 1:32, and mycelial phase Ab
<1:8. Antibody to TP antigen IgM, and antibody to F antigen
IgG were also positive. The patient was diagnosed with pulmonary
coccidioidomycosis associated with Sweet’s syndrome. Due to borderline
Coccidioides CF (titer 1:16) and yeast phase Ab (titer 1:32), the
infectious disease team recommended treating the infection as
disseminated coccidioidomycosis with fluconazole 800 mg daily for at
least 3 months even though there was no clinical evidence apart from
yeast phase Ab titer of 1:32.