A 55-Year-Old Peruvian Woman With Unresponsive Pulmonary Tuberculosis

A 55-year-old Peruvian woman presented to our outpatient clinic with a 7-month history of cough, whitish sputum with bloody streaks, and occasional hemoptysis (up to 125 mL). She also had moderate chest pain and progressive shortness of breath without fever or weight loss. With the onset of symptoms, she noted the first of 4 sequential pruritic nodular skin lesions over different areas of her trunk, persisting for 1–2 months each. She had an abnormal chest radiograph and chest computed tomography scan (Figure 1) and had been started on a standard 4-drug regimen for tuberculosis during the past 2 months without improvement. Positive findings on the physical examination were a brown nodular lesion of about 2.5 cm in diameter under the right breast (Figure 2), and crackles on both lung bases. Laboratory tests showed a normal white blood cell count with an absolute eosinophil count of 5020 cells/μL. A sputum sample revealed a pathogen (Figure 3). What is your diagnosis?