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An alien in the heart: giant infective endocarditis

A 78-year-old woman was referred to our depart-ment because of acute confusion and somnolence.Her usual medication was corticosteroid injectiononce a month for hip arthrosis. The clinical exami-nation showed an obese patient. Blood pressure was90/60∞∞mmHg and heart rate 160∞∞bpm. On admission,the patient had fever (38.6°C) and meningism, but nofocal neurologic deficits were found. Heart and lungauscultation was normal. Because of progressive res-piratory insufficiency, the patient was mechanicallyventilated. Blood analysis showed an inflammatorysyndrome and mild renal failure. The cerebral CTshowed no focal lesions. An antibiotic regimen withampicilline and geomycine was started on the basisof suspected bacterial meningitides on lumbar punc-ture. A transthoracic echocardiography revealed endo-carditis with a giant vegetation on the posterior mitralvalve leaflet (P2) and a severe valvular regurgitation(figure 1: A, B, C). Transoesophageal echocardio-graphy confirmed the diagnosis and did not showperivalvular extension (figure 1D). Methicillin-sensi-tive