The Drenched Doctor

A CLINICAL PROBLEM-SOLVING article by Daniel Kaul from University of Michigan Medical School in Ann Arbor.
A 55-year-old male physician was seen in August because of a 1-week history of fever and night sweats. The patient also noted a persistent cough, which had previously been ascribed to esophageal reflux.
Three months earlier, he had received empirical treatment with a 5-day course of clarithromycin for fever and cough, with initial resolution of the fever and improvement, but not resolution, of the cough. The chest radiograph at that time revealed no infiltrate. There were calcified nodules near the hilum of each lung and a densely calcified hilar lymph node which had been noted on chest radiographs over the previous 30 years and attributed to healed histoplasmosis.
Over the next week, the fever and cough continued, and the night sweats increased in severity, drenching the patient's sheets as well as his nightclothes. On several occasions, his temperature was 38.4°C or higher. He returned to his physician's office; an examination showed no abnormalities. The patient's white-cell count was now 3700 per cubic millimeter.
Five days later, the white-cell count was 7200.
He was treated with ciprofloxacin. The fever diminished, but the fever and night sweats returned after the course of medication had been completed. The cough worsened, and the patient reported that it was exacerbated by swallowing foods and liquids.
In this case, the recognition of the pivot point — coughing on swallowing — was required for the correct diagnosis.