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CMAJ | APRIL 12, 2021 | VOLUME 193 | ISSUE 15 E517 A 59-year-old man presented to the emergency department with fever and chills that began 6 weeks earlier, when a symptomatic deep vein thrombosis (DVT) of the right posterior tibial vein had been diagnosed. The patient had also noticed word-finding difficulties and mild headache for the week before the current presentation. He did not have any chest pain, nausea or loss of consciousness. The patient was receiving anticoagulation treatment for his distal DVT with rivaroxaban (20 mg daily) because of his history of a squamous cell carcinoma of the tongue, which had been treated 2 years earlier. On physical examination, the patient’s body temperature was 38.1°C, with otherwise normal vital signs. Cardiac auscultation found a 3/6 holosystolic murmur heard best over the apex. Neuro logic examination was normal except for a subtle expressive aphasia. Vascular examination of the extremities was normal. Initial laboratory tests reported a leukocyte count of 4.4 (normal 4.8–10.8) × 109/L, a hemoglobin level of 131 (normal 140–175) g/L, an erythrocyte sedimentation rate of 17 (normal < 10) mm/h and a creatinine level of 92 (normal 49–93) μmol/L. The patient’s liver enzyme and electrolyte levels were normal. Two blood culture sets were drawn.

A 59-year-old man with persistent fever, aphasia and leg pain