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Why does this elderly man have a rash and a fever?

The fever had gone on too long for it to be flu, then it was followed by a rash – Dr Mike Wyndham looked for the clues

The fever had gone on too long for it to be flu, then it was followed by a rash – Dr Mike Wyndham looked for the clues

The patient

This 74-year-old retired teacher had suffered a myocardial infarction three years previously but had made a very good recovery. This was followed up with an angioplasty and stent insertion. He was a regular volunteer for medical student teaching as he had a prominent murmur of mitral incompetence. He had maturity onset diabetes that was well controlled with metformin.

His first consultation was in the middle of December at the height of the flu season. He had been unwell for 10 days with fever, joint pains and loss of appetite.

Clinically, the chest was clear and the cardiac murmur was unchanged from normal. His abdomen was normal and urinalysis was negative. He was sent away with a recommendation to take symptomatic medication.

Two weeks later, he returned, complaining of feeling weak, loss of appetite and constipation. He had noticed swelling of his ankles, a continuing fever and the appearance of a rash, particularly on his legs. Clinically, there were now ‘wet sounds' in his lungs.

First instinct

It wasn't the flu, as it seemed to have gone on too long. The persistence of fever certainly suggested infection. The wet sounds in the lungs and ankle swelling indicated some cardiac decompensation.

The question was whether the two problems were connected.

Differential diagnosis

• Atrial myxoma

• Lyme disease

• Polymyalgia rheumatica

• Subacute bacterial endocarditis (SBE)

The flu-like symptoms, fever and joint pain would certainly fit with Lyme disease. When there is cardiovascular involvement, there may be palpitations or the development of heart block. Shortness of breath may relate to myocarditis or pericarditis. However, the rash certainly did not appear to resemble erythema migrans, which is usually seen on the chest and abdomen.

Atrial myxomas are rare and usually develop in the left atrium. They may cause malfunction of the mitral valve and a murmur may be audible. Heart failure may result from the chronic presence of the tumour. But the presence of fever was not consistent with this diagnosis. Additionally, nothing was seen at the previous cardiological investigations.

Polymyalgia rheumatica causes muscle stiffness, which may in turn lead to joint pains. A fever may be present but the cardiac failure would not be explained by this diagnosis. Of course, this might have developed coincidentally.

The hidden clue

Making the diagnosis probably requires that all the pieces are incorporated into the jigsaw. The persistent fever, suggestion of cardiac failure and prominent cardiac murmur meant that an echocardiogram was essential. The presence of vasculitis suggested an immunological reaction, perhaps to infection.

In SBE, the symptoms may be split into two areas – those that directly relate to the heart and those that are embolic.

The flu-like symptoms, persistence of fever, and vasculitis in the presence of a cardiac murmur pointed strongly to SBE. The hidden clue was vegetations seen growing on the mitral valve demonstrated by a transthoracic echocardiogram. The patient was admitted immediately to hospital for antibiotic treatment.

Dr Mike Wyndham is a GP in Edgware, north London

Rash and fever

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