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JAMA Clinical Challenge
May 20, 2019

A Febrile, Hypotensive Patient With Bilateral Lung Crackles

Author Affiliations
  • 1Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles
  • 2Department of Cardiac Surgery, University of California, Los Angeles
JAMA. 2019;321(24):2460-2461. doi:10.1001/jama.2019.6546

A 61-year-old man with a history of hypertension presented to the emergency department with a 1-day history of fever, dyspnea, and generalized weakness. His vital signs were temperature, 38.4°C (101.1°F); blood pressure, 94/40 mm Hg; heart rate, 116/min; and respiratory rate, 26/min. He was diaphoretic and had poor dentition. A soft S1 was present on cardiac examination, and crackles were auscultated in basilar lung fields bilaterally. Three sets of blood cultures from different sites were obtained. Cardiology, cardiac surgery, and infectious disease physicians were consulted. A bedside transthoracic echocardiogram was performed, the patient was transferred to the intensive care unit, and a transesophageal echocardiogram was obtained (Figure 1).