New cutaneous nodules associated with pulmonary symptoms

Abstract

A 26-year-old Hmong man, a central California farm laborer with no medical history, presented with 1 week of productive cough and intermittent fevers. A chest radiograph found probable lobar pneumonia with a cavitary lesion, and he was discharged with azithromycin for presumptive community-acquired pneumonia. Despite initial improvement, a pruritic skin eruption developed on his extremities and spread centripetally after completion of azithromycin. Upon re-evaluation in the emergency department, examination found erythematous nodules with central ulceration in the setting of ongoing cough. He denied arthralgia and recent travel but reported an 8-pound weight loss. Punch biopsy specimens were obtained (Fig