Cases from the Osler Medical Service at Johns Hopkins University

PRESENTING FEATURES: A 62-year-old woman was admitted for fever, malaise, and fatigue. She had traveled to the United States from the Ivory Coast 4 days before her presentation. Her initial symptoms, which had developed 2 days before admission, continued about 12 hours but resolved shortly after treatment with nonsteroidal anti-inflammatory drugs (NSAIDs). However, the fever, which recurred on the day of admission and was accompanied by severe sweating and malaise, motivated her to visit the emergency department. She had no known chronic medical conditions and was taking no medications other than the NSAIDs. On physical examination, she was febrile (102.9°F), with a blood pressure of 137/72 mm Hg, a pulse of 90 beats per minute, and a respiratory rate of 17 breaths per minute. In general, she appeared to be in no distress. The cardiac examination revealed a II/VI systolic murmur at the right upper sternal border. Her spleen was palpable 10 cm below the left costal margin. There were no skin rashes, swollen joints, or neurologic abnormalities. The remainder of her physical examination was unremarkable. What is the diagnosis?