A 30-year-old man with no significant medical history, who had been working his entire life as a gold miner in rural Colombia, came to the infectious disease outpatient clinic at our institution with a two-month history of high spiking fevers, generalized lymphadenopathy (Figure 1), right lower quadrant pain, and vertigo. He did not report any weight loss or night sweats. He also reported headache, diplopia, and somnolence that developed over the past two weeks.At physical examination, he had a Glasgow coma scale of 13/15, a positive Romberg test result, ataxia, somnolence, a right third-nerve palsy, diffuse lymphadenopathy, and mild abdominal tenderness in the right lower quadrant. He was hospitalized, and computed tomography of the neck, thorax, and abdomen showed diffuse lymphadenopathy in cervical (Figure 2), axillary, mediastinal, periaortic, pulmonary hilar, mesenteric (Figure 3), and inguinal chains; and thickening of the cecum and appendix (Figure 3). Magnetic resonance imaging of the brain showed a mesencephal ring-enhancing mass with associated edema (Figure 4).Laboratory data showed a leukocyte count of 12,600 cells/ mL (65% neutrophils), a hemoglobin level 8.7 mg/dL, a platelet count of 220,000/mL, and a creatinine level of 0.9 mg/dL. A test result for human immunodeficiency virus was negative, and meningitis was ruled out by cerebrospinal fluid studies (protein level = 35 mg/dL, glucose level = 78 mg/dL, leukocyte count = 2 cells/mL, and 0 erythrocytes/mL), including fungal and mycobacterial cultures.A biopsy of neck lymphadenopathy and the cecum by colonoscopy showed multiple, narrow-based budding yeast cells with steering wheels the shape of Paracoccidioides brasiliensis by staining with Grocott's methenamine silver ( Figure 5).
