Images in Clinical Tropical Medicine

California from Botswana at 7 years of age. He presented with B symptoms: intermittent fever, fatigue, and 20 kg weight loss progressive over 6 weeks. He had no relevant past medical history; his last trip to Africa was in 2002. On examination, he had axillary and inguinal lymphadenopathy; nodular skin ulcerations were present on the forehead, fingers, scalp, and chest (Figure 1C). Laboratory studies showed low hemoglobin (10.7 g/dL), a negativeMycobacterium tuberculosis interferon-g release assay, and a negative serology for human immunodefi-ciency virus. A concern for lymphoma prompted a positron emission computer tomography scan (PET CT-coronal images shown), which showed extensive tracer uptake in mediastinal and axillary lymph nodes (Figure 1A-anterior coronal image shown), vertebral bodies and pedicles, and the right testis (Figure 1B-posterior coronal image shown).1 An excisional biopsy (hematoxylin and eosin [H&E] stain) of a left axillary lymph node showed spherules consistent with Coccidioides species (Figure 1D). The serum Coccidioides complement fixation titer was 1:512; cerebrospinal fluid analysis was unremarkable. Fluconazole 800 mg/d by mouth led to clinica