A 44-Year-Old Man With Persistent Upper Respiratory Infection

A middle-aged man with no significant medical history presents to his local urgent care with flu-like symptoms but sees no improvement after starting antibiotics.

A 44-year-old man with no significant medical history presents to his local urgent care center after 3 days of fevers, sore throat, rhinitis, coughing, and myalgia. He reports that his girlfriend who works at a daycare center has had similar flu-like symptoms for the past week and that she has noted something has been going around in the daycare center. He is started on amoxicillin.

Several days later he visits his primary care provider with worsening symptoms. He is started on azithromycin with no improvement. On day 7, his girlfriend calls 911 and he is brought to the local hospital emergency department with severe fatigue, lower extremity swelling, and marked dyspnea on exertion. He is unable to lay flat as a result of orthopnea. 

On physical exam, he is found to be tachypneic, tachycardic, and with jugular vein distention to his jaw line. Auscultation of his lungs reveal bilateral crackles. Mean arterial blood pressure is 57 mm Hg. Laboratory results reveal markedly elevated serum creatinine, white blood cell counts, and liver transaminases. Troponins are markedly elevated, and he is anuric.

What is the most likely diagnosis?

A.      Acute respiratory distress syndrome

B.      Fulminant viral myocarditis

C.      Acute severe mitral insufficiency secondary to ruptured papillary muscle

D.      Myocardial infarction with resulting systolic heart failure

E.      Cardiac sarcoidosis