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A 50 year old man was originally referred in 1983 with a nine week history of multiple complaints of headache, backache, profuse night sweats with rigors, anorexia, and general malaise. He was a registered intravenous drug abuser for many years, and had been recently prescribed methadone. On admission, he had a temperature of 38°C and a maculopapular rash over his arms and legs. He was jaundiced and anaemic with a haemoglobin concentration of 7.2 g/dl (4.47 mmol/l). His jugular venous pressure was raised at 4 cm above the clavicle with a prominent V wave. On auscultation the patient had a pansystolic murmur at the left sternal edge which was accentuated on inspiration. An echocardiogram showed massive vegetations on the tricuspid valve with severe tricuspid regurgitation. The diagnosis of infective endocarditis was made and confirmed with blood cultures positive for Staphylococcus aureus septicaemia. In November 1983 the patient underwent total valvectomy without insertion of an artificial valve because of the potential for further infections while he continued his rehabilitation. In 1985 he stopped all intravenous drug use. He remained well in New York Heart Association functional class I until 1997 when he underwent cardioversion for atrial fibrillation. Despite an early success, the patient remained in controlled atrial fibrillation and is now under consideration for a tricuspid valve replacement. The figure shows a transoesophageal view of the right ventricular inflow tract, where no tricuspid valve can be seen.
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