Case 1

A 25-year-old Caucasian male with a history of a benign functional heart murmur presented to the emergency department for evaluation of 10 days of dyspnea with minimal exertion, such as walking a few blocks or climbing a flight of steps. Dyspnea was accompanied by moderate, dull, left-sided chest pain, which had been progressively worsening over the previous 3-5 days. The symptoms initially occurred only with exertion, but progressed to last 30-45 minutes after discontinuation of activity. He also noticed palpitations during these episodes, but did not try any remedies for his symptoms. Of note, two weeks prior to presentation, the patient had been camping in Shenandoah National Park, Virginia for four days. During that trip, he sustained over 30 mosquito bites, but never noticed any tick bites or rashes. He also traveled to Brazil five months ago, during which time he took malaria prophylaxis.