A 46-year-old lady, on anticoagulation for recent deep vein thrombosis (DVT), presented with severe pain in her left arm and was found to have necrotic left fingers with compromised blood supply to the left hand. On examination, the patient had poor dentition and a short systolic murmur at the apex. Her initial investigations were as follows: the white blood count (WBC) was 9 × 109/L (normal 4–11 × 109/L), C-reactive protein (CRP) 51 mg/L (normal 0.3–1 mg/dL), erythrocyte sedimentation rate (ESR) 31 mm/h (normal 0–29 mm/h), antinuclear antibody (ANA) 1:2560 (normal <1:160), anti-dsDNA 59 IU/mL (normal <30 IU/mL), C3 0.53 g/L (normal 0.88–2.01 g/L), and C4 0.05 g/L (normal 0.15–0.45 g/L). These results indicated the possibility of an ongoing inflammatory process. Blood cultures were negative. Transthoracic echocardiography showed mild complex mitral regurgitation originating from this area (). Other valves were within normal limits. Transoesophageal echocardiography (TOE) showed an echogenic mass measuring 0.5 cm × 0.9 cm attached to the posterior mitral valve leaflet at the junction between P2 and P3 ( and see, ). Further microbiological testing including viral panel, parasitic panel, respiratory cultures, and stool cultures was negative. Screening for antiphospholipid syndrome was negative. A renal biopsy revealed vasculitis glomerulonephritis with focal segmental proliferative lesions consistent with Class III lupus nephritis.