The advantages and limitations of echocardiography in a unique presentation of double-sided endocarditis from intravenous drug use

A 25-year-old female intravenous drug user presented with a three-week-history of fever and myalgias and was found to have infective endocarditis affecting the mitral and tricuspid valves.  Blood cultures grew methicillin sensitive Staphylococcus aureus. Computed tomography showed emboli in multiple organs.  Transthoracic echocardiogram revealed large vegetations on the mitral valve with moderate valvular regurgitation and a transesophageal echocardiogram identified a posterior mitral leaflet perforation.  The patient underwent urgent surgical intervention after developing respiratory distress from worsening congestive heart failure.  Intraoperative findings in addition to those found on echocardiography included a large abscess in the posterior wall of the left atrium.  The patient underwent mitral and tricuspid valve replacement due to valve damage.  This case shows a unique presentation of valvular involvement of infective endocarditis and the capabilities and limitations of echocardiography in assessing the extent of disease in this condition.