Unexpected

A 58 year old man complains of fever for 3 weeks associated with fatigue and lassitude. He is otherwise asymptomatic and has an unremarkable medical history.

He has never undergone any surgical or dental procedures and denies recreational drug use. There is no family history of malignancy.

A chest x-ray and urinalysis are found to be normal.

Select Relevant Investigations
Full Blood Count

Performed

WBC/DC: 15,000/mm3
N: 82%, L: 13 %
Hb: 10.2 g/dl
MCV: 70 fl (low)
MCH: 25 pg (low)
Platelets: 430,000/mm3

Blood Film: Microcytic hypochromic anemia
Blood cultures

Performed

The preliminary culture report shows Gram +ve cocci in two samples.

The definitive report shows isolation of Streptococcus bovis.
Echocardiography

Performed

The echocardiogram shows an oscillatory mass attached to the mitral valve with concomitant mitral regurgitation. There are no other structural cardiac defects. The left ventricular ejection fraction (LVEF) is 63%.
Colonoscopy

Performed

Colonoscopy shows an ulcerated fungating growth in the sigmoid colon. Multiple biopsies are sent for histology.

Select Relevant Management
IV Antibiotics
NSAIDs
Anti-Tuberculous therapy
GI Surgical referral