Case 40 -2009-A 29-Year-Old Man with Fever and Respiratory Failure

http://content.nejm.org/cgi/content/full/361/26/2558

This was a fascinating case. Can you guess the diagnosis?

A 29-year-old man was admitted in July 2009 to the critical care unit of this hospital because of fever and respiratory failure.

The patient had been well until 9 days earlier, when a nonproductive cough and myalgias in his legs developed. One week before admission, he had a temperature of 39.4°C, associated with headache. During the next week, sore throat and nasal congestion developed, the cough became productive of clear sputum, and he noted mild chest pain under his ribs during inspiration. Four days before admission, he was seen at the emergency department of another hospital. He did not have neck pain or photophobia. He reported finding a tick on his scalp 1 month earlier. On examination, he appeared in mild distress. The temperature was 38.2°C and the pulse 106 beats per minute; the remainder of the examination was normal. A rapid test of a specimen from a buccal swab was negative for influenza A and B antigens, and no parasites were seen on a peripheral-blood smear; other test results are shown in Table 1. Acetaminophen, ketorolac, and ceftriaxone were administered, and normal saline was infused. Doxycycline was prescribed, and he was discharged.

The patient returned the next afternoon because of persistent fever, cough, myalgias, low back pain, and new scrotal pain. The temperature was 39.0°C, and the other vital signs were normal. There were rhonchi in the left lower lung field, and the remainder of the examination was normal. A test for Lyme disease, sent the day before, was negative. Other test results are shown in Table 1. A chest radiograph showed incomplete segmental consolidation of the apical posterior segment of the right upper lobe and right hilar prominence, features suggestive of pneumonia and lymphadenopathy, respectively. Levofloxacin was prescribed, and he was sent home.

During the next 2 days, nausea and vomiting developed, with blood-tinged emesis. One day before admission to this hospital, the patient returned to the other hospital. The temperature was 38.6°C, the blood pressure 135/70 mm Hg, the pulse 113 beats per minute, the respiratory rate 34 breaths per minute, and the oxygen saturation 88% while he was breathing 4 liters of oxygen by nasal cannula. A chest radiograph revealed progression of the process in the right upper lobe and patchy air-space disease in the right lower lobe and the middle and lower lobes on the left side. Nucleic acid testing for Babesia microti and Anaplasma phagocytophilum and testing for serum antibodies to Borrelia burgdorferi, sent 3 days earlier, were negative. A rapid screening test for pharyngitis due to group A streptococcus and review of a blood smear for parasites were negative; other results are shown in Table 1. He was admitted to the hospital. Doxycycline, levofloxacin, gentamicin, ibuprofen, acetaminophen, ondansetron, guaifenesin–codeine cough syrup, and ranitidine were administered. Respiratory distress worsened. Testing for antibodies to Francisella tularensis was negative. Approximately 14 hours after admission, he was transferred to this hospital by helicopter and admitted to the critical care unit.

(hat tip pfi/Goju)