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A 56 year old obese woman with no significant past medical illness was referred to the cardiac centre with a one week history of worsening shortness of breath on exertion and a one year history of fatigue. There was no history of fever, night sweats or loss of weight. On examination, she was apyrexial and mildly clubbed; there was a splinter haemorrhage on the right middle finger and she was pale. Cardiac auscultation revealed an ejection systolic murmur and an early diastolic murmur in the aortic area. Urine analysis showed microscopic haematuria. The erythrocyte sedimentation rate was 119 mm/hour, the C-reactive protein was 62 mg/l, and the plasma creatinine was 137 μmol/l. The patient's ECG and chestx ray were normal. A transthoracic echocardiogram showed a 1.5 cm mobile vegetation attached to the non-coronary cusp of the aortic valve and there was severe aortic regurgitation (below left). A transoesophageal echocardiogram demonstrated an abscess cavity on the atrial side of the anterior mitral leaflet where the mobile vegetation on the non-coronary cusp of the aortic valve was in contact with the mitral valve (below right).
At surgery the presence of a kissing abscess on the anterior mitral leaflet arising from a vegetation on the non-coronary cusp of the aortic valve was confirmed. St Jude's valve prostheses were implanted in the aortic and mitral positions. The patient made an uneventful recovery following surgery.