A 25-year-old woman with a history of depression, mitral-valve prolapse, and migraine presented with a 3-day history of fever, arthralgia, and a severe generalized headache that was not characteristic of her previous migraines.

On examination, the patient was afebrile, with a pulse rate of 120 beats per minute and a blood pressure of 98/41 mm Hg. She was somnolent but easily arousable, with normal mentation, and the neurologic examination was normal. Laboratory studies showed a normocytic anemia and severe thrombocytopenia. A peripheral-blood smear revealed few platelets and some schistocytes. Thrombotic thrombocytopenic purpura(血栓性血小板减少性紫癜)was suspected, plasma exchange and corticosteroid therapy were initiated with improvement of her symptoms and hematologic abnormalities. However, five days after discharge, the patient returned because of a recurrent headache and emesis, and falling platelet count to 23,000 per cubic millimeter. Blood cultures now showed β-hemolytic group C streptococcus. A trans-esophageal echocardiogram revealed ruptured chordae tendineae of the mitral valve leaflet(二尖瓣腱索断裂), possible leaflet perforation,  and severe regurgitation. This suggested infective endocarditis, not thrombotic thrombocytopenic purpura, as the unifying diagnosis.

This case discussed “How a clinical presentation prompted an incorrect diagnosis”, and asks clinicians to re-sweep the case and  the correct diagnosis of Myxoma" should’ve been made earlier.