Image of the Month: Concomitant Tricuspid and Mitral Native Valve Infective Endocarditis

A 33-year-old immunocompetent man was admitted to the authors' hospital with a one-month duration of fevers, chills, and non-productive coughs, and suddenonset weakness and ischemic pain of both lower extremities. Physical examination revealed crepitating rales heard over bilateral lung fields. On auscultation, a grade 2~3/6 systolic murmur was heard over the leftlower sternal border and apical area. Transthoracic echocardiography revealed a mobile mass on the tricuspid valve compatible with vegetation, in addition to concomitant mitral valve vegetation (Video 1). Thoracic computed tomography (CT) with contrast revealed cavitary lesions of the left and right lung fields (Fig. 1A and B). Abdominal CT showed a splenic infarction (Fig. 2A), a renal infarction (Fig. 2B), and thromboembolic occlusion of the distal aorta and right common iliac artery (Fig. 3). The patient denied any history of intravenous drug abuse. Blood cultures grew Streptococcus agalactiae (penicillin G-sensitive with a minimal inhibitory concentration ≤0.06 μg/ml). Video 1: Transthoracic echocardiography showing mobile masses on tricuspid and mitral valves compatible with vegetation on the apical four-chamber view.