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Endgames Case Review

A man with fever and breathlessness

BMJ 2019; 364 doi: (Published 21 March 2019) Cite this as: BMJ 2019;364:l1085
  1. David Hamilton, core medical trainee,
  2. Karen Lipscomb, consultant cardiologist
  1. Royal Bolton Hospital, Bolton, UK
  1. Correspondence to D Hamilton dohamilton{at}

A 42 year old man, born in Zimbabwe and living in the UK, presented with a two week history of fever, vomiting, and diarrhoea on a background of six months of increasing exertional dyspnoea.

His temperature was 38°C, heart rate 96 beats/min, respiratory rate 24 breaths per minute, blood pressure 82/57 mmHg, and saturations 100% on room air. On examination there was a loud first heart sound and mid-diastolic murmur. Blood results are shown in the table.

View this table:

Relevant abnormal blood results

He underwent chest radiography (fig 1).

Fig 1

Chest radiograph

He was treated for septic shock of unknown origin with piperacillin-tazobactam and 4000 mL intravenous fluid, after which he developed bilateral coarse crepitations on auscultation and marked type 1 respiratory failure. He improved after 12 hours of ventilation on the intensive care unit and was successfully extubated. Blood cultures were later positive for Streptococcus oralis.


  1. What does the chest radiograph show?

  2. What is the most likely underlying diagnosis?

  3. What is the most likely cause of the rapid deterioration and improvement of respiratory function?


1. What does the chest radiograph show?

It shows evidence of pulmonary oedema with perihilar congestion, fluid in …

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