[NEJM] image challenge

May 30, 2019

large,ulcerative lesion on the tongue(lt), bx of the tongue lesion(rt)

A 34-year-old man with a history of human immunodeficiency virus (HIV) infection presented to the emergency department with a 1-week history of headache, fever, and confusion. On physical examination, a large, ulcerative lesion was noted on his tongue (Panel A). The patient's CD4 count was 39 cells per cubic millimeter (reference range, 500 to 1450), and his HIV viral load was 197,000 copies per milliliter. A chest radiograph showed patchy infiltrates in both lungs. A biopsy specimen of the tongue lesion was obtained (Panel B). What is the most likely diagnosis?

 

1. Sarcoidosis 
2. Lingual tuberculosis 
3. Disseminated coccidioidomycosis 
4. Disseminated aspergillosis 
5. B-cell lymphoma 

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source: https://www.nejm.org/image-challenge

 

 

 

 

 

 

 

The correct answer is disseminated coccidioidomycosis. IgG antibodies to coccidioides were detected in the blood and cerebrospinal fluid (CSF), and coccidioides antigen was detected in the blood, CSF, and urine and in fluid obtained on bronchoalveolar lavage. A biopsy specimen of the tongue lesion was obtained, and staining with hematoxylin and eosin revealed multiple fungal organisms consistent with coccidioides spherules.