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A 41‐year‐old man, a known intravenous drug user with positive hepatitis C serology, was admitted with a 4‐day history of malaise, rigors and night sweats.
Clinical examination demonstrated a pyrexia (39.4°C), sinus tachycardia (120 bpm) and hypotension (blood pressure 85/55 mm Hg). Auscultation disclosed pansystolic and early diastolic murmurs. There were no peripheral stigmata of endocarditis. Initial blood tests showed a haemoglobin of 105 g/l; white cells 20.3×109/l; neutrophils 18.5×109/l; C reactive protein 250 mg/l; urea 17.3 mmol/l and creatinine 178 mmol/l.
Transthoracic and transoesophageal echocardiograms showed a non‐dilated hyperdynamic left ventricle with small vegetations on the mitral valve leaflets (arrows, panel A) and chordae tendinae and mild mitral regurgitation. There was a vegetation on a flail aortic left coronary cusp (arrow, panel B) that prolapsed into the left ventricular outflow tract together with severe aortic regurgitation (panel C). The tricuspid valve had a large vegetation on the septal leaflet (panel A) with moderate tricuspid regurgitation. A transthoracic subcostal view also revealed a small vegetation on the pulmonary valve (arrow, panel D)
Infective endocarditis was diagnosed and treatment was started with empirical antibiotics and inotropic support. Blood cultures grew group G Streptococci. Intravenous benzylpenicillin and gentamicin were started.
Emergency aortic valve surgery with a homograft and tricuspid valve vegetectomy were performed 10 days after admission. He was discharged after a further 6 weeks of antibiotic treatment.
Most echocardiographically demonstrated endocarditis occurs on a single valve; the involvement of two valves occurs much less frequently, and triple‐ or quadruple‐valve involvement is extremely rare.1