Excerpt

A 39-year-old intravenous drug user was admitted for fever and abdominal pain. Physical examination revealed mild abdominal tenderness and an incidental finding of jugular venous distention with a holosystolic murmur best heard at the left sternal border. There was no clubbing or cyanosis. Blood tests showed normochromic, normocytic anemia and leukocytosis. Computed tomography (CT) of the abdomen and pelvis showed splenomegaly and pelvic ascites. An urgently performed laparotomy revealed no evidence of bowel perforation or ischemia. Three sets of peripheral blood culture confirmed methicillin-sensitive Staphylococcus aureus bacteremia. Transthoracic echocardiogram revealed a destructed tricuspid valve with a huge, mobile vegetation and severe eccentric regurgitation with right-to-left shunting across the interatrial septum (Fig. 1a, b). Transesophageal echocardiogram confirmed a patent foramen ovale (PFO) and a right-to-left shunt on the agitated saline test (Fig. 1c). Despite a course of cloxacillin, he developed widespread embolic phenomena including pulmonary embolism, multiple cavitary lung lesions, and multiple intracranial hemorrhages. In retrospect, the initial acute abdominal presentation could have been a minor embolic event. The patient underwent tricuspid valve replacement and closure of the PFO. However, due to the deep tricuspid valve annulus infection, he developed complete heart block post valvular surgery and became pacing dependent. He developed sudden massive hemoptysis 20 days after valvular surgery due to ruptured mycotic aneurysm in a bronchial artery and he finally succumbed.

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