Index of Suspicion

Case 1 Presentation

A 16-year-old girl presents to the ED with persistent fever and headache for 9 days. She was previously healthy except for a tooth extraction 3 weeks ago, for which she received penicillin. She denies shortness of breath, visual changes, vomiting, diarrhea, palpitations, joint pain, weight loss, cough, or urinary symptoms. She had been seen repeatedly in the ED and had normal examination findings and unremarkable CBC, CSF analysis, and urinalysis. She was given intramuscular ceftriaxone and sent home with a prescription for oral azithromycin. After returning to the ED today, she is admitted.

Physical examination shows a temperature of 102.2°F (39.0°C), heart rate of 120 beats/min, respiratory rate of 18 breaths/min, and blood pressure of 103/71 mm Hg. Auscultation of the heart reveals a mid-systolic click followed by a 2/6 crescendo-decrescendo murmur.

Her WBC count is 11.0×10³/mcL (11.0×10⁹/L) with 27% bands. Chest radiography demonstrates normal findings. A blood culture that had been obtained during a previous ED visit grew Streptococcus viridans. Subsequently, multiple blood cultures continued to grow S viridans. Transthoracic echocardiography showed no evidence of vegetations but did show a small pericardial effusion and mitral valve prolapse.

Case 2 Presentation

A 15-year-old girl presents to a New England ED in early October with a 1-day history of headache. She states that the headache is bitemporal and accompanied by neck pain, myalgias, fever, and vomiting. The teenager relates that her pediatrician recently diagnosed her with migraines, but this headache is worse than any she has had before. She denies any history of trauma, recent illness, or travel. She lives in an urban neighborhood and does not take walks through wooded areas or remember being bitten by a mosquito or tick recently. She has no pets and is an only child.

Physical examination reveals an uncomfortable adolescent girl …