A 53-year old man presented to the ED with complaints
of fevers and chills for 5 days. Two days prior, he started
having generalized arthralgias and a painfully numb left
index finger. Similar symptoms had also begun on his
left great toe (See Figures D and E, Color Plates page
19). The patient denied recent trauma, although he was
unsure if he had sustained an insect bite on the dorsal
aspect of his left hand 8 hours prior to the onset of
symptoms. Three sets of blood cultures obtained prior
to admission were positive for methacillin-sensitive
Staphylococcus aureus. The patient was treated with
intravenous nafcillin and gentamicin. A transesophageal
echocardiography was performed, which showed a friable
and perforated left coronary cusp of the aortic valve,
resulting in severe aortic insufficiency. The patient was
scheduled for emergent aortic valve replacement. It was
surmised that the initial site of infection was a badly
ulcerated blister located on the patient’s right great toe.