Case 21-1995

Abstract

A 33-year-old man was admitted to the hospital because of fever and increasing pain in the right leg.The patient had been well until 11 days earlier, when a sore throat developed while he was attending a meeting in Texas. No other symptoms occurred, and he was aware of only low-grade fever. During the next week the sore throat gradually improved. Three days before admission the sore throat was barely noticeable, although fatigue was present. Late in the afternoon he had a shaking chill that lasted more than an hour. The temperature was 38.3ºC and rose to 39.7ºC 30 minutes later. A physician found that his throat was clear. A single tender left submandibular lymph node, less than 1 cm in diameter, was palpated. The hematocrit was 46.6 percent, the white-cell count was 16,700 per cubic millimeter, and the platelet count was 175,000 per cubic millimeter. Radiographs of the chest were normal. A viral syndrome was suspected, and acetaminophen was prescribed. On the next day he felt better, except for a mild headache and anorexia; the temperature was 38.3ºC. One day before admission the headache resolved, but the temperature again ranged as high as 38.3ºC. That evening pain developed above the right medial malleolus and worsened progressively. Early the next day he could not walk because of increasing pain and was brought to the hospital by ambulance.The patient was a physician who performed research on neuromuscular problems; he had no exposure to animals or pathogenic microorganisms. There was a history of hives after treatment with penicillin at 10 years of age. Gilbert's syndrome was first noted three years before admission. There was no history of leg trauma, risk factors for infection with the human immunodeficiency virus, nausea, vomiting, diarrhea, cough, dyspnea, thoracic or abdominal pain, pain in joints other than the ankle, dysuria, urinary frequency, urethral discharge, rash, or nuchal rigidity.The temperature was 37.3ºC, the pulse was 100, and the respirations were 18. The blood pressure was 120/80 mm Hg.On physical examination the patient appeared lethargic and acutely ill. There was diffuse erythema over the chest that blanched on pressure; no lymphadenopathy or cutaneous signs of sepsis were found. The conjunctivae were injected; the head was normal in other respects, and the neck was supple. The lungs, heart, and abdomen were normal. The right calf was slightly swollen, with a circumference of 37 cm, as compared with 35 cm on the left side. Poorly defined erythematous streaks were observed over the medial malleolus. There was tenderness on deep palpation of the right calf, and Homans' sign was present. No tender cord was palpated. The peripheral pulses were full and equal. No joint swelling or limitation of movement was detected at the ankles or other joints, and no peripheral edema was present. Neurologic examination was normal.The prothrombin and partial-thromboplastin times were normal, as were the values for urea nitrogen, creatinine, protein (albumin and globulin), magnesium, calcium, phosphorus,...