The patient is a 53-year-old man with 2 weeks of fever, sore throat, malaise, intermittent vomiting and diarrhoea. He had developed dyspnoea 2 days prior to presentation to the emergency department. He denied rashes, cough, abdominal pain, insect bites and chest pain.

The patient history is significant for coronary artery disease, hypertension, rheumatoid arthritis and hyperlipidaemia. The patient denied previous episodes of presyncope or syncope. Medications included amlodipine 5 mg daily.

The patient had travelled to Connecticut within 1 week of developing the febrile illness.

Physical examination revealed temperature …