This patient has blastomycosis, a fungal infection predominantly found in the southeastern/south-central United States as well as areas bordering the Ohio and Mississippi river basins and Great Lakes, with most cases reported in Mississippi, Arkansas, and Wisconsin. Exposure to soil has been identified as an important risk factor for the acquisition of this disease. Blastomycosis can involve almost any organ, but the lungs, skin, and bones are most commonly involved. The combination of lung and dermatologic involvement and occupational-related exposure to clouds of dust in this patient would make blastomycosis the most likely diagnosis. The diagnosis can be confirmed by direct visualization of the organism on a wet prep of the sputum or pus from the ulcer. Treatment for blastomycosis includes many different antifungal agents, including fluconazole, itraconazole, and amphotericin. Although ketoconazole would be effective, drug interactions and side effects make this agent a less optimal choice.
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