A 27-year-old man presented to the emergency department with abdominal pain in the left upper quadrant and a pulsatile, painful lesion on the right hand. He reported a 6-week history of fevers, decreased appetite, and night sweats and a weight loss of 12 kg. The painful lesion on the palm had started as focal erythema but had become blue, raised, and pulsatile over a period of 2 weeks. Physical examination was notable for a temperature of 38.5°C and a grade 3/6 diastolic murmur throughout the precordium. Laboratory studies revealed a white-cell count of 18,000 per cubic millimeter. Computed tomography (CT) of the abdomen revealed wedge-shaped infarcts in the spleen and left kidney, and an echocardiogram showed a vegetation on a bicuspid aortic valve with moderate aortic insufficiency. Cultures of two blood samples, which had been obtained in the emergency department, were positive for Streptococcus salivarius, and antibiotic agents were initiated. The patient received a diagnosis of subacute bacterial endocarditis, which was possibly related to poor oral hygiene and a recent dental procedure. CT angiography of the right arm revealed an aneurysm of the ulnar artery. The patient underwent aortic-valve replacement, followed by surgical repair of the mycotic aneurysm. His fevers and night sweats resolved 2 days after the initiation of a 6-week course of ceftriaxone.
Bashaar K. Alibrahim, M.D.
George Wharmby, M.D.
University of British Columbia, Vancouver, BC, Canada