A 65 year old man is seen because of fever, headache, sore throat and vomiting
Dr. David Durack
Professor of Medicine
Duke University Medical Center


A 65 year old man is seen because of fever, headache, sore throat and vomiting.

He had been in excellent health until approximately one week earlier when he noted a sudden onset of a headache, ocular erythema and halitosis. On the 3rd day of his illness, he began sneezing and coughing, and noted bilateral pleuritic chest pain. On the 6th day of his illness, the patient began projectile vomiting productive of dark bilious fluid. At this time, he complained of fever so intense that he would not allow himself to be covered with even the lightest clothing. He also complained repeatedly of insatiable thirst. Although he drank copious amounts of water, he obtained little relief from his thirst, at least in part, because of persistent vomiting.

The patient has had no prior serious illnesses. He drinks wine in moderation and does not use tobacco. He is taking no medications and has no known allergies.

The patient is a resident of Athens, Greece, where he has lived his entire life, except for short excursions throughout the eastern Mediterranean. His early years were spent in the military where he rose to the rank of commanding general of the armed forces. In recent years he has devoted himself to politics.

The patient is married. Both of his children by this marriage, sons aged 30 and 25 years, have died recently of illnesses similar to the patient’s. Another son (by his mistress), aged 10 years, is alive and well. The patient’s father died in battle at 47 years of age. The condition of his mother is unknown. He has a brother and a sister. His sister recently died in her mid 60’s of an illness similar to the patient’s. The condition of his brother, who is also approximately 60 years of age, is unknown.

An illness similar to the patient’s has afflicted large numbers of his fellow residents of Athens. The epidemic began roughly a year prior to the onset of the patient’s illness, one year after the outbreak of hostilities with a neighboring city state. Interestingly, although enemy forces have besieged Athens continuously during this period, their troops appear not to have been affected by the illness raging within the city proper. Refugees entering the city from the surrounding countryside, however, have been quickly affected. The disease attacks all age groups and socioeconomic strata, with the highest attack rates occurring among physicians and other care givers. The illness, which is reported to have originated in sub-Saharan Africa, had not been seen in Athens prior to the current epidemic. It is believed to have entered Athens through Piraeus, the city’s port. In addition to Athens, much of the eastern Mediterranean is now afflicted with the disease. The current epidemic has waxed and waned since its appearance without apparent seasonality. Of those who have contracted the disease, approximately a quarter have died. Persons recovering exhibit immunity to further attacks of the disease. Unfortunately, such persons are sometimes permanently disabled by residua of the disease, such as encephalopathy, blindness, and/or distal necrosis of extremities. Although there have been reports of dogs and birds dying after feeding on the corpses of those succumbing to the illness, these reports are unsubstantiated.

The patient is alert and oriented, and extremely weak. He appears well-nourished, although moderately dehydrated. The pulse is rapid and thready. Respirations are deep. The patient complains of an intense fever, and yet his skin is moist and normothermic to the touch. The head is dolichocephalic. The conjunctivae are injected. The oropharynx is red, inflamed and covered with clotted blood. The breath is fetid. Diffuse rales, ronchi and wheezes are heard throughout both the lungs. There is a generalized, erythematous, maculopapular rash.

Supportive therapy consisting of cool baths is administered without relief. On the 9th day of illness, the patient develops profuse diarrhea, which unfortunately, is not examined for blood or inflammatory cells. Progressive dehydration and debilitation ensues. Cardiovascular collapse occurs on the 11th day of illness, and the patient dies.

View the historical background of the Plague of Athens.

Final diagnosis