Fever With Shivering for Two Months in a Young Man

A young man came to the OPD with fever and shivering for the past two months. Fever was undocumented with shivering and especially would spike at night. It was associated with sweating as well.

The patient has been visiting different hospitals and private clinics and received antibiotics and analgesic medicines multiple times. He also received injectable ceftriaxone and other injectable medicines for suspected Typhoid Fever.

The patient lost about 9 kgs over the past two months and felt anorexic. He did not have any abdominal or urogenital complaints but had a mild dry cough without shortness of breath.

There is no history of headache or focal weakness. He had developed weakness, lethargy, and body pains without any history of joint swelling or redness.

Examination of the patient with Fever and Shivering:

The patient was running a temperature of 99F. He looked toxic but very cooperative.

Examination of the hands revealed Clubbing. The hand examination was otherwise normal.

He was mildly anemic but not jaundiced. He did not have any significant lymphadenopathy or swelling in the legs.

Neck examination was normal and the thyroid was not tender or enlarged.

The abdomen was soft and non-tender with mild splenomegaly. The chest examination was unremarkable and so was the fundus examination.

Examination of the precordium revealed a displaced apex beat with a grad 3 pan-systolic murmur that was best audible over the apex with radiation to the axilla.

Summary of the patient with Fever and Shivering:

A young male presented to the OPD with undocumented fever with shivering and weight loss. On examination, he had clubbed fingernails, splenomegaly, and a pan-systolic murmur over the apical area.

What is the most likely diagnosis?

What investigations should be done in this patient to reach a diagnosis?

Hint: See the trans-thoracic echocardiogram of this patient.

A brief discussion …

A brief discussion will follow covering these topics once a few answers are received:

• Causes of Fever with Shivering
• Causes of Fever lasting longer than two to three weeks
• Uncommon causes of Fever
• When to Worry? When not to worry?