Acute mitral valve endocarditis complicated by complete atrioventricular block, junctional escape rhythm, and skin manifestations

A 19-year-old female patient with no history of heart disease was admitted to the hospital with fatigue, fever, and a rash on the hands and feet. The laboratory tests revealed white blood cells count of 13.4×103 /uL and a C-reaktive protein 113 mg/L. The patient was referred to the cardiology department to determine the cause of fever. Osler nodules and janeway lesions were observed on the patient’s hands and feet; the fingers were cyanotic due to peripheral embolisms (PE) (Fig. 1a, 1b). Complete atrioventricular block with junctional escape rhythm, which is a very rare electrocardiographic finding, was observed (Fig. 1c). Transthorasic ecocardiography showed an approximately 14-mm-long vegetation on the anterior mitral leaflet (Fig.1d). Transesophageal echocardiography showed a 15-mm-long fibrillary like vegetation on the A-3 mitral scallop (Fig. 2a, 2b). Moderate mitral regurgitation (Fig. 2c) and bicuspid aortic valve were also noted (Fig. 2d). A preliminary diagnosis of infective endocarditis (IE) was made based on the results of blood culture reports; antibiotic treatment was initiated.