A Bird's-Eye View of Fever

A CLINICAL PROBLEM-SOLVING article by Alfred Ian Lee, from Brigham and Women's Hospital, Boston.
A 78-year-old man presented with a 4-month history of worsening fatigue, generalized weakness, and anorexia, and reported an unintentional weight loss of about 25 lb.
He reported subjective fevers, chills, drenching night sweats, dry mouth, a nonproductive cough, dyspnea with minimal exertion, and nausea with occasional emesis. He became light-headed on standing and had become largely bedridden in the preceding month.
The patient reported the development of escalating pain, erythema, and blurred vision in his right eye, without antecedent trauma, 18 months earlier; 1 month before the onset of these symptoms, he had traveled to the Great Smoky Mountains, after which he sustained a brief febrile illness. Ophthalmologic evaluation showed vitritis in one eye.
Vitreous fluid showed a polymorphous cellular infiltrate. CT of the chest revealed mild basilar lung atelectasis and nodules measuring 1.6 cm in diameter on both adrenal glands.
The constellation of symptoms of this patient points to the presence of a disseminated infectious, inflammatory, or malignant process. The antecedent travel to the Great Smoky Mountains is of particular interest. An interactive medical case associated with this article is available at NEJM.org. [Original Article]