A fifty-four year old boating captain from Uruguay began to notice a slow, progressive change in his voice.  He has spent much of his work docking into ports in Brazil and Central America. He went to see his primary care provider, who ordered some blood tests–these were notable for a sodium of 130, potassium of 5.2, Cr of 1 mg/dl and WBC count of 11, with mild eosinophilic predominance. An upper endoscopy was obtained, which showed an ulcerating lesion near the vocal cords with the presence of a small fistula. This lesion was excised and sent for pathology and culture. On exam, he had another small ulcer inside his nasal septum, and some axillary lymphadenopathy.

He smoked cigars occasionally, and drank 2 glasses of wine every night. He had a history of hypertension, otherwise no history of COPD, diabetes, coronary disease or any other medical issues. He has one dog on the boat with him at all times, who has not been ill. He ate lots of fish while at sea, and did each undercooked beef and steak on occasion. No recent sick contacts, and no prior history of TB. He had no fevers or night sweats at home, and no weight loss but was feeling more short of breath over the past three months. His biopsy revealed the diagnosis, and treatment was started promptly.

Based on the history given, what is the most likely cause of his symptoms?

1. Parasitic Infection
2. Fungal Infection
3. Neoplastic Process
4. Autoimmune Disorder
5. Bacterial Infection
6. Viral Infection