case_images: PMC4677589_01
case_images: (a) EKG on admission with an old incomplete left bundle branch block, (b) EKG showing second-degree AV block (2:1) - Mobitz type II and (c) EKG showing ventricular pacing.
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case_images: F0001
case_images: EKG initially showed an old incomplete left bundle branch block (Fig. 1a); chest X-ray was normal and lumbar spine X-ray revealed degenerative disc disease with suspected discitis and spinal stenosis noted significantly at L3-L4, L4-L5, and L5-S1. A repeat EKG revealed Mobitz type II atrioventricular block (Fig. 1b). Antibiotic therapy was continued with continuous cardiac monitoring; however, due to persistent symptomatic bradycardia, epicardial pacing was done (see Fig. 1c).
case_images: (a, b) MRI of the lumbosacral spine showing a prominent marrow edema pattern adjacent to the L3-L4 and L5-S1 suggestive of osteomyelitis/discitis (see arrows): (a) coronal T1-weighted image and (b) sagittal T1-weighted image.
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case_images: F0002
case_images: MRI of the spine revealed L3-L4 and L5-S1 disc endplate changes with significant marrow edema suggestive of discitis and vertebral osteomyelitis (Fig. 2a and b).
case_images: Three-phase bone scan showing focal abnormal radiotracer accumulation at the L3-L4 and L5-S1 intervertebral disc level suspicious for osteomyelitis/discitis.
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case_images: F0003
case_images: Three-phase bone scan also showed increased uptake at L3-L4 and L5-S1 (Fig. 3).
case_images: Transthoracic echocardiogram (four-chamber view) showing vegetation on tricuspid valve (see arrow).
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case_images: F0004
case_images: Because of the presence of low-grade fever and a new murmur, transthoracic echocardiogram was done which showed tricuspid vegetation with moderate tricuspid regurgitation (Fig. 4).
case_images: (a, b, and c) Transesophageal echocardiogram showing large vegetation on tricuspid valve (see arrows). No paravalvular complications visualized.
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case_images: F0005
case_images: TEE revealed large fixed vegetation measuring 27x16 mm2 on the right atrial aspect of the tricuspid valve but no valve ring or septal abscess (Fig. 5a-c).