The patient has pulmonary coccidioidomycosis. The history of recent travel to Arizona with exposure to a construction site is the key exposure history in this case. Most patients with coccidioidomycoses pneumonia have a self-limited course of illness; however, immunosuppressed patients (eg, patients with HIV) may have a fulminant course with respiratory failure. Some patients (commonly females) with coccidioidomycosis present with erythema multiforme or erythema nodosum. The triad of fevers, erythema nodosum, and arthralgias has been termed desert rheumatism. The patient is less likely to have pneumococcal pneumonia given her exposure history and bilateral diffuse infiltrates on chest radiograph. She has no history of exposure to blastomycosis. Her recent CD4 count of 350 cells/mm3 makes P. jiroveci pneumonia less likely.
Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennetts principles and practice of infectious diseases. 6th ed. New York: Elsevier/Churchill Livingstone; 2005.
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