Abstract
A 48-year-old man with cough, fever, and malaise was found to have disseminated Coccidioides immitis infection. He had a history of rheumatic heart disease with mitral valve stenosis and paroxysmal atrial fibrillation. A porcine mitral valve replacement had been performed one year earlier. His daily medications included warfarin, 5 mg; hydroxyzine, 10 mg; digoxin, 0.25 mg; and slow-release verapamil, 480 mg.Therapy was started with amphotericin B, 2.5 gm given intravenously, followed by itraconazole, 200 mg twice a day. Four weeks later the patient complained of malaise and nausea. On examination, he appeared to be in no acute distress. Blood pressure was 121/54 mm Hg; pulse, 55 beats per minute and regular; respirations, 18 per minute; temperature, 37.0°C. Examination of the skin, head, ears, eyes, nose, throat, and neck were unremarkable. The chest was clear. There was a grade 2 systolic ejection murmur, with no rub or gallop. The remainder of the examination was unremarkable.The complete blood cell count and serum levels of electrolytes, blood urea nitrogen, creatinine, and glucose were normal. The ECG is shown.
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