A 75 year old Japanese woman with rheumatic valvar disease (aortic steno-insufficiency and mitral steno-insufficiency) was       admitted because of a two month history of fever and general malaise. Eleven years previously she was diagnosed with aortic mixed valve disease and mixed mitral valve disease by echocardiography and cardiac catheterisation, which revealed grade III aortic regurgitation.

On admission the patient's temperature was 37.1°C and blood pressure was 120/76 mm Hg, with irregular heart beats of 112 per minute because of pre-existing atrial fibrillation. A pansystolic murmur of grade 3/6 was audible at the apex. There was no early diastolic murmur. A transoesophageal echocardiogram performed after admission revealed extensive vegetation involving the right and non-coronary cusps of the aortic valve which plugged the aortic orifice during diastole, and abolished pre-existing aortic regurgitation. Blood cultures revealed streptococcal bacteraemia (Streptococcus mitis).

The patient underwent aortic and mitral valve replacement surgery successfully. The extensive vegetations were attached to the right and non-coronary cusps; the fibrous thickening and adhesion commissures and cusps of the aortic valve were pathologically consistent with a rheumatological aetiology. Similar rheumatic findings were confirmed at the mitral valve.