Case Challenge #13

History of Present Illness

A previously healthy 20-year-old white male presents with high fever (up to 40°C, unresponsive to anti-inflammatory drugs), appetite loss, nausea and vomiting, persistent headache and a feeling of significant malaise for 5 days. He was diagnosed at an outside hospital with an atypical infection and had received azithromycin for 3 days, without any improvement.

Denies travel, IV drug use, new sexual partners or tattoos. He has no animal exposure.

Past History

He does not use tobacco products or alcohol and has not taken any medications. Family history is negative. Several episodes of tonsillitis and tonsillar abscess as a child.

Physical Exam
  • T: 38.3°C, BP: 80/50mmHg,  P: 100 bpm, O2 sat 92%.
  • Bilateral conjunctival chemosis
  • L cervical lymphadenopathy
  • Cracked, red lips and tongue, dry mucus membranes
  • Tachycardia with S3 and S4 gallop
  • Faint macular skin rash of his trunk, edema of palms and soles, desquamation of fingertips
  • Examinations of his lungs, abdomen, neurological and musculoskeletal systems were normal.
Labs
  •  WBC: 13.2 (91% neutrophils), Hematocrit 33%, Platelets 541
  • Creatinine normal
  • ESR 127; CRP 30; LDH 263
  • All blood tests for autoimmune diseases were negative
  • Blood and urine cultures negative
Imaging
  • The results of a chest X-ray, an electrocardiogram and a transthoracic echocardiogram were normal.

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