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A 24-year-old male with a painful and cold lower extremity


Clinical introduction A 24-year-old male presented to the emergency department with intense pain in his right lower extremity. He has a medical history significant for systemic lupus erythematosus and antiphospholipid syndrome. He also had four prior episodes of deep venous thromboses on rivaroxaban. The patient stated that early in the morning, he started to feel intense pain that started from his knee and progressed to his calf, with associated numbness and paraesthesia. On physical examination, the limb felt cold with absent right popliteal and dorsalis pedis pulses. He was immediately taken for embolectomy after discovery of a distal common femoral artery occlusion. The patient's blood cultures remained negative. X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) of the aortic valve (figure 1A) and colour Doppler (figure 1B) are shown.

Figure 1

Visualisation of the aortic valve on (A) X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) and (B) colour Doppler.

Question What is the diagnosis and management for this patient (assuming the patient will stay anticoagulated for life)?

  1. Infective endocarditis (IE); antibiotics and valve replacement

  2. Libman-Sacks endocarditis; corticosteroids

  3. IE; antibiotics only

  4. Libman-Sacks endocarditis; valve replacement

  5. Libman-Sacks endocarditis; continuing anticoagulation only


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