A 63-year-old man presented to the family medicine clinic with a nonpainful skin lesion on his left forearm. The lesion had grown rapidly since he first noticed it 2 weeks earlier. The patient reported having some purulent and blood-tinged fluid drainage from the lesion. He also experienced several weeks of low-grade fevers, nonproductive cough, and unintentional weight loss. One week earlier, he had been prescribed antibiotics for presumed pneumonia, but his symptoms had not improved since completing treatment. The patient was a farmer in southern Indiana. His medical history was significant only for squamous cell carcinoma of the skin. He had no history of tobacco use.

Physical examination revealed a red, verrucous plaque on the lateral aspect of the proximal left forearm. The plaque was firm, raised, nontender, and 2.5 cm in diameter (Figure 1).

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

• A. Blastomycosis.

• B. Coccidioidomycosis.

• C. Histoplasmosis.

• D. Pyogenic granuloma.

• E. Verrucous carcinoma.