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Abstract

CASE PRESENTATION

A 30-year-old female with a history of intravenous drug use presented to the hospital with left wrist pain. Physical exam revealed a left volar ulnar wrist abscess with purulent drainage, a holosystolic murmur heard best at the apex radiating to the axilla and Janeway lesions on the right hand and bilateral feet. A transthoracic echocardiogram revealed a 20 mm mobile vegetation on the mitral valve along with valve perforation and severe regurgitation consistent with bacterial endocarditis. On eye exam, Roth spots (Figure 1) were noted bilaterally. Roth spots are present in less than 2% of all infective endocarditis cases and are composed of immune complex microthrombi that lead to a localized vasculitis. Roth spots are one of the immunologic phenomena that make up the modified Duke criteria in endocarditis but they also appear in other conditions such as leukemia and diabetes. The patient continued to develop more Roth spots, however she did not experience any vision changes. Brain MRI revealed multiple septic emboli and abscesses. CT angiogram of the head revealed multiple foci of contrast outpouchings consistent with mycotic aneurysms. Her course was complicated by a spontaneous mycotic aneurysm rupture which required endovascular coiling.

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