Mr. G.S., a 48-year-old business consultant with an unremarkable past medical history save for obesity (122 kg/180 cm), migraines and “lactose intolerance,” returned in the spring from a 2-week trip to Europe and Russia. After landing in Toronto, he noted some irritation and a cramp-like feeling in his left leg. He went to a walk-in-clinic, was diagnosed with “phlebitis” and given anti-inflammatory agents. He took them but had no relief, so after arriving at home, he went to the local emergency room, where he also complained of dry cough. Mr. G.S. underwent venous doppler and CT chest scans. These were negative for DVT and pulmonary embolism (PE), and he was treated with a course of antibiotics and anti-inflammatories for leg pain.

The cough continued to progress, to the extent that at times he coughed up bile. He denied phlegm or hemoptysis, though. During the next couple of weeks, he experienced intermittent fever and night sweats. He had occasional symptoms of heartburn and reflux. He denied symptoms of abnormal bowel movements, bleeding per rectum, melena, joint pain or joint stiffness. He’d been working on weight loss over the past year and claimed to have lost 13^½ kg in the past 6 months, through various diets. There was no history of sexual contact overseas, genito-urinary symptoms or urethral discharge.

He took pantoprazole 40 mg a day, clarithromycin and budesonide/formoterol. He was a non-smoker and denied alcohol use. His work involved frequent travel to different continents.

Physical exam revealed a BP of 146/84 mm Hg and regular rhythm. There was no cervical or axillary lymphadenopathy noted. Heart sounds were distant but normal. Lungs were clear. Abdomen was soft and obese. No organomegaly was noted. There was no calf tenderness and Homan’s sign was negative. There was, however, chronic induration of both lower legs and ankles and a slightly tender cord-like structure on the medial aspect of the left knee in the left saphenous and popliteal veins. There were no skin lesions or lesions compatible with erythema nodosum.

A chest x-ray was unremarkable. ESR was normal at 14, as was his CBC and electrolytes.

The possibilities of viral syndrome, sarcodosis, TB (in view of travel, dry cough, fever, night sweats) and superficial phlebitis (DVT was ruled out) were considered, but a Mantoux test was negative.

Over the next 4 weeks, his symptoms continued to progress rapidly and he began experiencing ongoing fever and night sweats with a decreased appetite. In just one month, he developed superficial phlebitis involving the right leg and left arm, and he also developed DVT, PE and thrombophlebitis of the left internal jugular vein.

What’s wrong with Mr. G.S?