23-Year-Old Man With Fever and a Sore Thumb

Abstract

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Jacksonville, FL (J.A.C., W.C.P.); Adviser to residents and Consultant in Community Internal Medicine, Mayo Clinic, Jacksonville, FL (O.M.P.). A 23-year-old man presented to the emergency department with a 3month history of recurrent objective fever and malaise. He was otherwise asymptomatic, reporting no chest pain, shortness of breath, abdominal pain, nausea, vomiting, or diarrhea. His medical history was notable only for a bicuspid aortic valve, and his only past surgery was a dental procedure 4 months before presentation. He was currently taking no medications but noted allergy to penicillin and cephalosporins, leading to type I hypersensitivity. His family history was remarkable only for hypertension and type 2 diabetes mellitus in his father. He did not use alcohol, tobacco, or illicit drugs and was a college student. On physical examination, the patient was febrile (temperature, 38.2 C). His cardiovascular examination revealed an early grade 3/4 diastolic decrescendo murmur, loudest to auscultation in the third left intercostal space with radiation along the left sternal border. Carotid pulses were bounding with a rapid upstroke and collapse. His lung sounds were clear on auscultation bilaterally. Abdominal examination revealed a soft, nontender, nondistended abdomen with normal and active bowel sounds and no hepatosplenomegaly. His integument examination revealed a tender nodule on the right thumb. Results of laboratory testing, including complete blood cell count and electrolyte panel, were all within normal limits, except for a leukocyte count of 24.6 10/L (reference range, 3.5-10.5 10/L). Electrocardiography revealed sinus tachycardia. Chest radiography documented no consolidation, but mildly increased interstitial markings with mild cephalization of the vasculature were noted, findings suggestive of mild pulmonary vascular redistribution and interstitial edema. On initial blood stains and cultures, 4 of 4 specimens in 2 of 2 blood culture sets yielded gram-positive cocci in chains.