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JAMA Surgery Clinical Challenge
September 2013

Fifty-Two-Year-Old Woman With Neck Pain and Fever

Author Affiliations
  • 1Department of Medicine, Newport Hospital, Newport, Rhode Island
  • 2Division of Vascular Surgery, Boston Medical Center, Boston University School of Medicine and Public Health, Boston, Massachusetts
  • 3currently with the Division of Vascular Surgery, Louisiana State Health Science Center Shreveport, Shreveport, Louisiana
JAMA Surg. 2013;148(9):893-894. doi:10.1001/jamasurg.2013.312

A 52-year-old woman presented to the emergency department with a few days’ history of fever and left-sided chest and neck pain. She was otherwise healthy and had no history of drug abuse, recent travel, or trauma. On examination, she appeared unwell. Her blood pressure was 82/55 mm Hg, heart rate was 110 beats/min, and temperature was 38.5°C. The left neck was tender on palpation but she had no apparent deficits on neurological examination.

Laboratory evaluation included a white blood cell count of 9600/µL (to convert to  × 109/L, multiply by 0.001) with 19% bands. Electrocardiogram was normal with no evidence of ST segment changes. Computed tomography angiography of the neck showed a 1.4-cm, aneurysmal left carotid bulb with a hypodensity within the wall of the artery. There was a severe left common carotid artery stenosis. The carotid bulb was situated at the level of the middle portion of the second cervical vertebral body (Figure 1). Carotid duplex ultrasonography showed a left common carotid artery aneurysm and more than 80% stenosis of the common carotid artery. Transesophageal echocardiography revealed mitral valve thickening suspicious for infectious endocarditis. Computed tomography scan of the head showed multiple bilateral small hemispheric infarcts consistent with embolism. The patient was administered broad-spectrum antibiotics and was medically prepared for definitive surgery.

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