56-year-old patient with a history of type 2 diabetes and obesity. He was admitted for several weeks of fever, chills, general malaise, vomiting and diffuse pain in the thorax and lumbar region. On examination, the general condition was acceptable, temperature 39oC, and a systolic murmur of intensity II/VI in the mitral focus radiating to the left axilla, while the rest of the examination was normal. Blood tests showed white blood cells 11,400/mm3 (69% granulocytes), platelets 92,000/mm3, erythrocyte sedimentation rate 52mm in the first hour, glucose 281 mg/dl, triglycerides 279 mg/dl and alkaline phosphatase 322 IU/l, while the rest of the blood count, biochemistry and coagulation were normal. In the urine, 100 mg/dl protein, 250 mg/dl glucose and 25 red blood cells per field were detected in the sediment. The electrocardiogram showed an anterior haemiblockage as the only abnormality. Chest and spine X-rays, abdominal ultrasound and computed tomography were normal. Echocardiography shows an unstructured mitral valve with prolapse of both leaflets. Blood cultures showed Streptococcus agalactiae, so treatment was started with cefotaxime at a dose of 1 gram every 8 hours intravenously. Initially there was a good clinical response, with disappearance of the fever, but 5 days after starting treatment the patient began to experience palpitations, dyspnoea and orthopnoea, and the fever reappeared. At this time, the systolic murmur was IV/VI, and there was abundant crackles in both thoracic bases. New chest X-rays showed changes highly suggestive of acute pulmonary oedema. Follow-up echocardiography revealed further mitral valve destructuring, vegetations on both mitral valve leaflets and severe mitral regurgitation. Despite intensive treatment with diuretics, vasodilators, synotropic agents, high-dose penicillin and gentamicin, she progressed unfavourably, developed third-degree atrioventricular block, requiring the implantation of a temporary pacemaker, and died about 12 hours after the onset of dyspnoea, while preparations were being made for surgical treatment.
