A 31-Year-Old Man Comes to the Emergency Department Because of a High-Grade

question 134

Multiple Choice

A 31-year-old man comes to the emergency department because of a high-grade fever and multiple painful skin nodules that began 2 days ago.  The skin lesions are red and painful, and gradually developed on both arms before spreading to the chest and legs.  He also notes fatigue, poor appetite, dry cough, and mild shortness of breath.  One week ago, the patient was helping his father in the garden.
The patient had an allogeneic bone marrow transplantation for acute leukemia 3 months ago complicated by pneumonia, catheter-associated bacteremia, and chronic gastrointestinal graft-versus-host-disease.  His medications include prednisone, valganciclovir, and trimethoprim/sulfamethoxazole.  
His temperature is 39.4 C (103.0 F) , blood pressure is 90/60 mm Hg, pulse is 106/min, and respirations are 28/min.  Examination shows dry mucus membranes, diffuse crackles in the lung fields, and mild splenomegaly.  Skin examination reveals dry skin with multiple raised, erythematous, and tender nodules on his upper extremities, lower extremities, and upper chest.
Laboratory results are as follows:

The patient is admitted to the hospital and started on empiric antibiotic therapy.  Blood cultures are obtained and grow mold-like organisms.
Which of the following is the most likely cause of his condition?

• A)Aspergillus fumigatus
• B)Candida albicans
• C)Fusarium moniliforme
• D)Histoplasma capsulatum
• E)Nocardia braziliensis

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