A 70-year-old man presented with fever and delirium. His past medical history included mitral regurgitation, palindromic rheumatoid arthritis, autoimmune haemolytic anaemia, and thrombocytopenia. The main positive examination findings included harsh systolic murmurs in the mitral area and at the lower sternal border.
A head computed tomography (CT) did not reveal any acute intracranial pathology, and lumbar puncture yielded normal cerebrospinal fluid (CSF). Brain magnetic resonance imaging (MRI)and transoesophageal echocardiogram (TOE)were performed with a high suspicion of infective endocarditis(IE), and the former revealed several ischaemic emboli with some haemorrhagic transformation, and the latter demonstrating small vegetations in the anterior and posterior mitral valve leaflets (5-7mm and 2-3mm in each) with a tiny perforation in the anterior leaflet. Management of this patient involved treatment with intravenous (IV) antibiotics for 6 weeks, management in the coronary care unit with joint care by an infective disease specialist, a cardiothoracic surgeon and a neurologist so as to optimise the management.