rash

It is hard to make a quick diagnosis based on the findings you gave so far, yet, we can give you DD for these symptoms/signs:

Moving to California Valley will increase the risk of acquiring coccidiomycosis as an etiology for skin and bone disease like this case. It can also cause arthritis and fever.

If this patient turned to have HIV, Kaposi would be on the DD.

Sorry for not responding to you Dr.Burhan sooner than now, I was sick last wk and when I came back actually I was surprised that no one but you answered the case!!!!! a
Is it because this is not an interesting case or is it because you covered the whole DD in your answer?a
I really wonder why???and hope that somebody will give me answer so I know if I need to continue with putting cases here in the web or not.a

let's go back to the answer of this case, you are correct about your DD that you put there and for your interest the correct answer is: Coccidioidomycosis (commonly referred to as “valley fever ”) a
in this pt Cultures of the biopsy samples grew Coccidioides immitis. In addition, a coccidioidomycosis immunoassay revealed a complement fixation (CF) titer of 1:128, with positive immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies
Coccidioidomycosis is a fungal infection caused by inhalation of the spores of C immitis, a fungus endemic to the semi-arid areas of the southwest United States, particularly central California, Arizona, parts of Texas, and Mexico. Epidemiologic studies show that approximately 50-60% of patients experience no symptoms, whereas approximately 40% develop cold- or flu-like symptoms; these symptoms often resolve without treatment. About 10% develop pulmonary disease. A small percentage of patients develop disseminated disease, usually with involvement of the skin, the bones, and the central nervous system (CNS), though case reports have described involvement of almost every organ system. Less than 1% of patients experience CNS involvement, which is associated with the greatest morbidity and mortality and is generally fatal without treatment; these patients frequently require lifelong treatment. The risk factors for complication include the extremes of ages, any immunocompromised state (HIV, immunosuppressant use, cancer), and the third trimester of pregnancy. African Americans and Filipinos have the greatest risk of developing dissemination, whereas whites have the lowest risk.
In general, a mild infection does not require treatment. A moderate infection may be treated with either fluconazole or itraconazole. Moderate-to-severe infection may warrant treatment with amphotericin. Itraconazole is thought to have better bone penetration, whereas fluconazole has better CNS penetration. Surgical intervention is required in certain cases, such as those with bony involvement or progressive pericardial effusion. Newer pharmacologic agents, including voriconazole and posaconazole, are also being investigated for patients who have progressive disease resistant to standard therapy.

The patient in this case was initially placed on fluconazole at 800 mg/day. Because of the presence of high titers, as well as systemic symptoms, further workup was performed to evaluate for systemic involvement. The findings from chest radiographs and a lumbar puncture were unremarkable. A bone scan, however, showed multiple areas of increased uptake in the facial bones and the right clavicle, in several vertebral bodies, and in both hips. The diagnosis of disseminated coccidioidomycosis was made. With input from an Infectious Disease specialist, the dosage of fluconazole was increased to 1200 mg/day and the patient was kept in the hospital for several days. Eventually, the systemic symptoms resolved and the patient was discharged to home on continuing oral fluconazole therapy and close followup.

Thank you again Dr. burhan for participating in this case and sorry for the late answer.a
Salam from yasmeen elsham