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Skin/Oral Lesions in 20 yr old aquarium owner with cow/pig exposure. What is the diagnosis?

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heather805
heather805

20-year-old female with potato peeler cut on finger, got infected 2 weeks later with low-grade fevers, slowly resolved on Bactrim over 2 weeks, then afebrile, then similar lesion on OTHER hand in another superficial wound that seemed to get infected 2 weeks after the cut. Spread to the knuckle, mild cellulitis looking, joint involved, low-grade fevers, poor response to Bactrim. Has four fish tanks, works with cows/pigs in a muddy field, gardens, has 2 cats. Now, four months later still low-grade fevers but worsening, joint nearly resolved, increasing malaise, lethargy, new skin lesions on knees, lower legs oral lesions, nasal lesion. 3 months of clarithryomycin and rifampin with increasing temps, stopped one month ago. Was on Lamictal, stopped 1 month ago with no change. Pinky finger with lesion since onset of all. What is it?

Basic labs normal, ANA positive 1:360, 1:180. RDL antibody labs normal. ESR, CRP, procalcitonin normal. No joint pains, minimal myalgias. Now starting 2 weeks Augmentin.

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