Case: A pre-teen girl, living in central California, recently started on fluconazole, now presenting with a bilateral leg rash. What is your diagnosis? Click on the image for a larger view.
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Erythema nodosum, secondary to coccidioidomycosis
Erythema nodosum is a cutaneous reaction consisting of inflammatory, tender erythematous subcutaneous nodular lesions. The classically painful rash is located on the lower extremities and usually regresses spontaneously. It is associated with a wide variety of disease processes [1,2] including:
- Most common cause: Streptococcal infections
- Other causes:
- Behcet’s syndrome
- Oral contraceptive use
- Viral infections
Coccidioidomycosis is endemic to certain arid parts of the Southwest United States. Erythema nodosum is the most characteristic reactive cutaneous manifestation of coccidioidomycosis. It presents 1-3 weeks after onset of illness and is usually self-limited . While strep infections are the most common cause of erythema nodosum, in a patient who has recently visited the American southwest, suspect coccidioidomycosis.
Master Clinician Bedside Pearls
Stuart Swadron, MD – Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California (provided to ALiEM and recorded by Swadron, 2014)
- Psychos DN, Voulgari PV, Skopouli FN, Drosos AA, Moutsopoulos HM. Erythema nodosum: the underlying conditions. Clin Rheumatol. 2000;19(3):212-6. PMID: 10870657.
- Schwartz R, Nervi S. Erythema Nodosum: A Sign of Systemic Disease. Am Fam Physician. 2007 Mar 1;75(5):695-700 PMID: 17375516.
- DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol. 2006 Dec;55(6):929-4.2 PMID: 1711021.
UCSF-Fresno Emergency Medicine Residency