Tricuspid valve endocarditis presenting as multifocal cavitating pneumonia

A young man with multifocal cavitating pneumonia presented with early abscess formation secondary to Staphylococcus aureus bacteraemia treated with intravenous (IV) flucloxacillin. Further workup with transthoracic echocardiography revealed a large vegetation on the tricuspid valve with at least moderate tricuspid regurgitation; however, there were no peripheral stigmata of infective endocarditis. There was no history of intravenous drug use, but he had a history of administering frequent intramuscular recreational steroid injections. He also had a recent history of a loose tooth. In addition, there were multiple skin excoriations from scratching related to anxiety. Transoesophageal echocardiography confirmed two vegetations on the tricuspid valve, the largest measuring 21 mm with evidence of severe tricuspid regurgitation. The findings were discussed in the cardiac surgery multidisciplinary meeting and the consensus was for initial sterilisation with IV antibiotics followed by surgery.