Case 18-1973

Presentation of CaseA 66-year-old woman was admitted to the hospital because of fever.She was well until 21 months previously, when there was the onset of progressive fatigue. Seventeen months before admission she entered the hospital because of increasing fatigue, with dyspnea, anorexia and weight loss. There was a history of excessive use of alcohol in the past. Physical examination revealed no lymphadenopathy. A Grade 3 precordial systolic ejection murmur was heard. The liver span was normal; the spleen extended nearly to the level of the umbilicus and was firm and nodular. There was + + + + asterixis. . . .