A 46-year-old man, known to have an undiagnosed asymptomatic congenital heart defect, had a high temperature in November 1979. He was treated with antibiotics which were at first effective but pyrexia reappeared two weeks later. Cephalosporin was given intravenously for 10 days, but the patient became very weak, and haemorrhagic purpura appeared on the legs; evening pyrexia persisted. Finally, in May 1980, he was admitted to this hospital; bacterial endocarditis was suspected and penicillin started. At physical examination the patient appeared very ill and febrile, with gross hepatosplenomegaly. A grade 4/6 harsh pansystolic murmur was heard in the second and the third left intercostal space followed by a grade 1/6 diastolic murmur. The second heart sound was almost inaudible on the pulmonary area. The electrocardiogram and chest x-ray film appeared to be within normal limits. The M-mode echocardiogram (Fig. 1) showed multiple dense echoes on the posterior leaflet of the pulmonary valve, which showed abnormal movement. The two dimensional echocardiographic examination (30° sector scan) (Fig. 2) showed large polypoid vegetations freely moving with the cardiac cycle between the outflow tract of the right ventricle and the main pulmonary artery. Repeated blood cultures grew Staphylococcus cutis. Treatment with cefuroxime led to a brief remission of fever with apparent clinical improvement but high fever reappeared after 10 days despite continuous treatment and finally the patient developed a left lower lobe infarction with pleural effusion. As he was so ill, cardiac catheterisation and angiocardiography, previously planned, were abandoned and cardiac surgery was performed on the evidence of the echocardiographic diagnosis on 5 June. The pulmonary artery was incised transversely above the level of the valve. A quadricuspid non-stenotic valve was seen; the medial leaflet was ruptured and covered by an overgrowth of necrotic tissue (Fig. 3); a small ventricular septal defect was found just below the pulmonary valve which was excised. A biological prosthesis was inserted, and the ventricular septal defect sutured with four stitches on Teflon pledgets. Culture of the valve grew Staphylococcus cutis.
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