Case 16

A 24-year old, female graduate student in biology presented with exhaustion, weakness and a low grade fever. She was pale and showed poor ability to concentrate.

Her history revealed that she had gradually become increasingly tired and weakened over the past two months. She had experienced low-grade fevers over the past month and felt she would need to drop out of her graduate program if she did not get this under control. She had had a severe strep throat about a year earlier and showed some signs of rheumatic fever at the time. She had had minor dental surgery about two months earlier.

On examination, she had a temperature of 100F. She had slightly enlarged cervical lymph nodes. She had a heart murmur, with abnormal valve sounds. Her ears, eyes and throat were clear. She had clear lungs and there were no significant findings in other systems.

1. What would be your primary diagnosis of this patient?
   1. autoimmune heart failure due to rheumatic fever
   2. subacute bacterial endocarditis
   3. acute bacterial endocarditis
   4. generalized viral infection
   5. protozoal endocarditis
2. What agent do you think is causing this problem?
   1. Streptococcus pyogenes caused the problem
   2. Staphylococcus epidermidis
   3. Streptococcus pneumoniae
   4. Herpes simplex
   5. H. fowlerii
3. How would you make a definite diagnosis?
   1. I would look for rheumatoid factor in the serum.
   2. I would get a blood culture and culture for Staphylococcus epidermidis or viridans Strep.
   3. I would do a blood culture and look for beta hemolytic colonies.
   4. I would do a serum assay for the presence of herpesvirus.
   5. I would do a chest x-ray and look for the inflammatory signature of the protozoa.
4. Which of the following is a common outcome when this disease is untreated?
   1. The patient may have a stroke.
   2. The patient may develop and aneurysm.
   3. The patient may develop glomerulonephritis.
   4. Any of the above could occur.
   5. None of the above could occur.