case_images: PMC8120542_01
case_images: Thoracic radiographs. Three-view thoracic radiographs obtained at the initial referral appointment. Enlargement of the cardiac silhouette can be noted on the (a) dorsoventral and (b) right lateral projections (left lateral projection not shown). The caudal right pulmonary artery and vein are mildly distended. A diffuse unstructured interstitial pulmonary pattern is noted with a focal alveolar pattern in the right caudal lung lobe
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case_images: PMC8120542_01_10.1177_20551169211012346-fig1.jpg
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case_images: Three-view thoracic radiographs revealed generalized cardiomegaly with left atrial (LA) enlargement and a diffuse, mild, unstructured interstitial pulmonary pattern (Figure 1).
case_images: Initial echocardiogram. (a) Right parasternal long-axis view. There is a large pedunculated lesion arising from the papillary muscle (*). The endomyocardium in the region of the basilar septum is effaced and replaced by an irregular heterogeneous lesion extending into the left ventricular lumen and the myocardium (^). (b) Right parasternal short-axis view at the level the left ventricular papillary muscles. There is an irregular cauliform-like lesion (arrow) extending into the left ventricular lumen most consistent with vegetative endocarditis. These lesions represent infectious endomyocarditis
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case_images: PMC8120542_01_10.1177_20551169211012346-fig2.jpg
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case_images: An echocardiographic examination by a board-certified cardiologist revealed multiple oscillating lesions associated with the anterior leaflet of the mitral valve and trace mitral regurgitation (Figure 2).
case_images: Recheck echocardiogram. Right parasternal long-axis view. The previously noted endocarditis lesion has reduced in size with a small hyperechoic region noted at the basilar septum (*) and hyperechoic lesion on the septal leaflet of the mitral valve (>). There is also progressive left atrial (LA) enlargement
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case_images: Echocardiographic examination revealed a marked reduction in the size of the vegetative lesion on the mitral valve, as well as a reduction in the size of the hyperechoic LV myocardial lesions (Figure 3).
case_images: Electrocardiogram (ECG) at the time of arrhythmia diagnosis six-lead ECG paper speed 50 mm/s, amplitude 20 mm/mV. There is an underlying sinus rhythm with ventricular bigeminy. Ventricular ectopy (*) appears to be right ventricular in origin based on the left bundle branch morphology. The sinus complexes are prolonged, consistent with a right-bundle branch block (QRS duration 0.08 s)
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case_images: There was also frequent, single right-sided (left bundle branch morphology) ventricular ectopy, which at times occurred as periods of ventricular bigeminy (Figure 4).