A 55-year-old-woman, presented with complaints of exertional dyspnea for 6 months, numbness of legs for 4 months and low-grade intermittent fever for 2 months. She had a ventricular septal defect (VSD) first detected 20 years ago. Examination revealed a pansystolic murmur in neoaortic area, slightly decreased power in right lower limb, but normal deep tendon reflexes. Blood tests revealed moderate anaemia, high erythrocyte sedimentation rate and elevated C-reactive protein. Contrast enhanced computed tomography of chest showed multiple irregular nodules in both lung with central cavitation and surrounding consolidation (Fig. 1A and B). Her blood cultures were sterile, nerve conduction study showed right peroneal motor axonal neuropathy, and transthoracic echocardiograph showed moderate VSD, mild aortic and mitral regurgitations but no vegetations. Anti-neutrophil cytoplasmic (ANCA) vasculitis was considered a strong possibility, however, ANCA against proteinase 3 and myeloperoxidase was negative. In this scenario, a reassessment of possibilities and applying Occam's razor, infective endocarditis was reconsidered, and transesophageal echocardiography revealed moderate VSD (9mm) with left to right shunt, one mobile vegetation (10.7mm) on non-coronary cusp of the aortic valve and one on (11.6mm) right side of inter-ventricular septum with severe aortic regurgitation (1C and D). A diagnosis of infective endocarditis with septic pulmonary embolism was made. She received four weeks of parenteral antibiotics, followed by repair of VSD, aortic valve replacement and mitral valve repair, and is doing well. Infective endocarditis (especially culture negative) can often masquerade as vasculitis.1,2

Fig. 1.

(A and B) Contrast enhanced computed tomography of chest showed multiple irregular nodules in both lung with central cavitation and surrounding consolidation. (C and D) Transthoracic echocardiography showing ventricular septal defect with two vegetations on non-coronary cusp and right side of interventricular septum.

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