A 25-year-old man was admitted with a 6-day history of fevers, chills, and malaise. He noted that symptoms began with upper respiratory congestion and a sore throat. Two days later, he developed sharp pleuritic chest pain and nonproductive cough. The chest pain was left-sided and positional, exacerbated when supine, and relieved when sitting forward. When symptoms did not abate with ibuprofen, he visited the emergency room. On arrival, he was febrile, with a temperature of 101.0deg F, pulse of 114 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 122/77 mm Hg. He appeared mildly uncomfortable. Physical examination revealed poor dentition, shotty cervical lymphadenopathy, a pericardial friction rub, and decreased breath sounds at both lung bases. Peripheral white blood cell count was 16.3 x 10~9/L, 86 polymorphonuclear leukocytes. Hemoglobin was 13.5 g/dL, and platelet count was 348 x 10~9/L. Serum chemistry panel was notable for sodium (133 mEq/L) and potassium (2.8 mEq/L). Hepatic panel revealed an alkaline phosphatase level of 242 U/L (range, 30-115 U/L); alanine aminotransferase, 97 U/L (range, 0-48 U/L); aspartate aminotransferase, 27 U/L (range, 0-40 U/L); total bilirubin, 2.4 mg/dL (range, 0-1.3 mg/dL); and direct bilirubin, 1.4 mg/dL (range, 0-0.2 mg/dL). A chest radiograph was performed in the emergency department (Fig.1). Follow-up chest computed tomography (CT) with intravenous contrast is shown (Fig. 2A, B). The patient was given empiric intravenous metronidazole and cefotaxime.
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