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Clinical presentation The patient is a 60-year-old Japanese man who presented with a 2-week history of fevers, myalgias, fatigue, and a sore throat. He was treated as an outpatient with amantadine and clarithromycin for 5 days prior to admission without improvement. During this period, he also noted increasing right knee pain without any swelling, as well as poor appetite and a 10-lb weight loss. He did not report any history of rashes, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, or diarrhea. There was no history of recent travel, contacts with people who are sick, or animal exposures. After an initial workup, he was admitted to the general medical ward and placed on broad-spectrum antibiotics. On the second hospital day, he was transferred to the medical ICU for severe tachycardia and tachypnea.