Blurred vision, epistaxis, and fever in a young man

Abstract

Dr. William Binder: Today’s case is that of a 32-yearold man who presented to the Emergency Department (ED) because of complaints of sore throat, tactile fever, blurred vision, and shortness of breath. The patient stated that he had been seen at an outside clinic 2 weeks earlier for a sore throat. He was treated with amoxacillin for 7 days, did not feel improved and was given azithromycin and prednisone. Two days before presentation, the patient returned to his doctor’s office with complaints of dyspnea on exertion and dyspepsia. He also reported continued blurred vision and a temperature to 39.2°C (102.6°F). He was prescribed albuterol and metoclopromide and sent home. Because he still did not feel well, the patient came to our ED with the above complaints. In addition, he reported several episodes of epistaxis and night sweats during the previous 2 days. He denied weight loss, abdominal pain, diarrhea, urinary symptoms, headache, or rash. Are there any questions regarding the history? Dr. Vicki Noble: Epistaxis and night sweats are concerning for some type of consumptive process. Did he have anything to suggest coagulopathy in his past history and review of systems? Was there any sign of platelet or coagulation factor dysfunction on physical examination? Dr. Binder: The patient’s past medical history was significant only for hernia surgery 8 months before presentation. He denied any bleeding complications during or after the surgery. He had no allergies, and he denied the use of illicit drugs, tobacco, and alcohol. He was originally from Brazil, moved to the United States 7 years ago, and now works in retail. On review of systems, he reported no easy bruising and no additional symptoms. On physical examination, the patient had a temperature of 37.9°C (100.3°F), the blood pressure was 123/70 mm Hg, respiratory rate was 18 breaths/min, heart rate was 114 beats/min, and pulse oximetry was 96% on room air. During his stay in the ED his pulse oximetry decreased to 90% on room air and 94% on 2 liters of nasal cannula oxygen. The patient was a minimally ill appearing man, in no obvious distress. He was well groomed, and he did not smell of ketones. Examination of the head, ears, and neck was normal. The conjunctiva were pale. Discs were not visualized. His visual acuity was 20/30 in both eyes. Examination of the mouth showed dried blood staining the posterior oropharynx. The chest was clear to auscultation bilaterally; the heart was tachycardic without murmurs, and the pulses were equal throughout. The patient’s abdomen was soft and with no organomegaly. On genitourinary examination the patient’s testes were descended bilaterally, nontender, and demonstrated no masses. His extremities were normal and without edema, and he had no petecchiae, purpura, ecchymosis, or rash. Neurologically, he was completely intact, with normal gait, normal cranial nerve function, and normal strength and sensation. Dr. Eric Nadel: Are there any thoughts on this patient’s presentation?