It's on the tip of my tongue.

A 48-year-old white woman was admitted to the hospital with low-grade fever, night sweats, fatigue, nonproductive cough with dyspnea, bilateral knee pain, and swelling that progressed slowly over 6 weeks. She was a 30-pack-year smoker, and had received outpatient antibiotic therapy with clarithromycin and then cephalexin without improvement. The admission chest radiograph showed bilateral interstitial infiltrates, and an effusion was seen on knee radiographs. She was treated with levofloxacin, cefepime, and methylprednisolone with some improvement, but fevers persisted up to 104 degrees F/40 degrees C. She also developed multiple painful skin nodules (Figure 1) and an enlarging painful tongue ulcer (Figure 2). Her bilateral knee swelling and pain also worsened, and a bone scan showed increased activity. Skin biopsy showed acute and chronic inflammation with an abscess that contained "yeast" (Figure 3). Fungal culture from the skin lesion and joint fluid aspirate grew Blastomyces dermatitidis. Urine antigen and blood antigen enzyme-linked immunoassays for B. dermatitidis were positive. The patient was started on a 6-month course of itraconazole oral solution with slow resolution of her joint inflammation and skin lesions over the next several weeks.

Benefits and harms of doxycycline treatment for Gulf War veterans' illnesses: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: It has been hypothesized that certain Mycoplasma species may cause Gulf War veterans' illnesses (GWVIs), chronic diseases characterized by pain, fatigue, and cognitive symptoms, and that affected patients may benefit from doxycycline treatment. OBJECTIVE: To determine whether a 12-month course of doxycycline improves functional status in Gulf War veterans with GWVIs. DESIGN: A randomized, double-blind, placebo-controlled clinical trial with 12 months of treatment and 6 additional months of follow-up. SETTING: 26 U.S. Department of Veterans Affairs and 2 U.S. Department of Defense medical centers. PARTICIPANTS: 491 deployed Gulf War veterans with GWVIs and detectable Mycoplasma DNA in the blood. INTERVENTION: Doxycycline, 200 mg, or matching placebo daily for 12 months. MEASUREMENTS: The primary outcome was the proportion of participants who improved more than 7 units on the Physical Component Summary score of the Veterans Short Form-36 General Health Survey 12 months after randomization. Secondary outcomes were measures of pain, fatigue, and cognitive function and change in positivity for Mycoplasma species at 6, 12, and 18 months after randomization. RESULTS: No statistically significant differences were found between the doxycycline and placebo groups for the primary outcome measure (43 of 238 participants [18.1%] vs. 42 of 243 participants [17.3%]; difference, 0.8 percentage point [95% CI, -6.5 to 8.0 percentage points]; P > 0.2) or for secondary outcome measures at 1 year. In addition, possible differences in outcomes at 3 and 6 months were not apparent at 9 or 18 months. Participants in the doxycycline group had a higher incidence of nausea and photosensitivity. LIMITATIONS: Adherence to treatment after 6 months was poor. CONCLUSION: Long-term treatment with doxycycline did not improve outcomes of GWVIs at 1 year.