A 47-year–old man with history of bicuspid aortic valve presented with a 3-week history of fatigue, fever, chills, worsening shortness of breath, and pain on his left hand. Physical examination showed a systolic ejection murmur on the right and left upper sternal borders and an early diastolic murmur on the left lower sternal border. Skin examination revealed a very tender, round erythematous nodule on the left palm, which the patient has noticed for the last 3 weeks and described as very painful (Figure 1).There was no evidence of splinter hemorrhages, conjunctival hemorrhages, Janeway lesions, or fundoscopic findings of endocarditis. Laboratory results showed leukocytosis. ECG showed normal sinus rhythm with PR interval of 374 ms (Figure 2A). Chest x-ray revealed pulmonary edema. Blood cultures were drawn and the patient was started on IV antibiotics. Transesophageal echocardiogram showed aortic valve with vegetations, perivalvular abscess, and communication between the sinus of the noncoronary cusp and the right atrium with severe aortic regurgitation, flail tricuspid septal leaflet, tricuspid vegetation, and severe tricuspid regurgitation (Figure 2B). The patient was taken to the operating room for surgical repair. Blood cultures grew coagulase-negative staphylococcus.
- © 2014 American Heart Association, Inc.