Multisite Infective Endocarditis With Mural Vegetations in the Right Atrium and Right Ventricle

A 59-year-old reclusive man was found down in his home, presumably for at least 4 days. This had been preceded by progressive shortness of breath and profound generalized weakness for 2 weeks. There had been no recent use of intravenous drugs prior to onset of acute illness. On admission to the hospital, his blood pressure and body temperature were normal. He was tachycardic at 120 bpm in the presence of bilateral diffuse coarse crackles and decreased breath sounds at bases by chest auscultation. There was a 3/6 holosystolic murmur best heard at apex with radiation to the axilla. He was noted to have significant edema in bilateral lower extremities, with dry gangrene of the hands and feet bilaterally. His leukocyte count was 15,300/L (88% neutrophils) and the C-reactive protein was 146 mg/L. An echocardiogram showed sinus tachycardia, with no other abnormalities. The initial blood cultures grew out methicillin-sensitive Staphylococcus aureus and Streptococcus anginosus. He was placed on an intravenous antibiotic regimen of oxacillin and penicillin G.Transthoracic echocardiogram revealed multiple vegetations involving both …