A 49-year-old man comes to the office due to 4 months of cough and weight loss. His medical history is otherwise unremarkable, and he takes no medications. The patient is a farmer who lives in Mississippi. He does not use tobacco, alcohol, or illicit drugs. His temperature is 100.2°F. Examination shows right lobe crackles. Chest X-ray reveals a pulmonary infiltrate in the right upper lobe. Bronchoscopy with transbronchial biopsy shows granulomatous inflammation. HIV testing is negative.

Which of the following is most likely causing this patient's symptoms?

The most likely cause of this patient's symptoms is histoplasmosis, a fungal infection caused by inhalation of spores from soil contaminated with bird or bat droppings.

Explanation:

Based on the given information, the patient is a 49-year-old farmer from Mississippi who presents with a chronic cough, weight loss, and pulmonary infiltrates. The presence of granulomatous inflammation on bronchoscopy suggests an infectious or inflammatory etiology. Given the patient's occupation and location, it is important to consider the possibility of an environmental exposure or infection.

One potential cause to consider is histoplasmosis, a fungal infection caused by inhalation of spores from soil contaminated with bird or bat droppings. Histoplasmosis is endemic in certain regions, including the Mississippi River Valley, and individuals who work in or live near areas with bird or bat droppings are at increased risk of exposure.

Common symptoms of histoplasmosis include cough, weight loss, and pulmonary infiltrates, which align with the patient's presentation. The negative HIV testing suggests that the patient's symptoms are not due to opportunistic infections associated with immunosuppression.

Other potential causes to consider include tuberculosis, sarcoidosis, and lung cancer. However, given the patient's occupation and the presence of granulomatous inflammation, histoplasmosis is the most likely cause of the patient's symptoms.

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