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An ECG that changed in a febrile patient

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f585 (Published 06 February 2013) Cite this as: BMJ 2013;346:f585

This article has a correction. Please see:

  1. Thomas Joseph Ford, cardiology registrar1,
  2. Greg Cranney, director of cardiology1,
  3. Annette Li, final year medical student2
  1. 1Department of Cardiology, Prince of Wales Hospital, Sydney, NSW 2031, Australia
  2. 2Kensington Campus, University of New South Wales, Kensington, NSW 2052, Australia
  1. Correspondence to: T J Ford thomasjford{at}gmail.com

A 50 year old man with a history of injecting drug misuse was admitted as an emergency with a reduced level of consciousness and left arm weakness after five days of swinging fever, rigors, and headache. His medical history included hepatitis C infection, paroxysmal atrial fibrillation, and a recent hospital admission with discitis and psoas abscess. His temperature was 38.4°C, but he was haemodynamically stable and alert. He had a soft early diastolic decrescendo murmur along the left sternal border. Splinter haemorrhages were present, along with a small digital infarct of the left third toe and mild upper motor neurone pattern weakness in the left arm. Laboratory investigations confirmed a normocytic anaemia and leucocytosis and blood cultures grew meticillin resistant Staphylococcus aureus. Computed tomography of the brain showed a hypodense area in the left frontoparietal area consistent with infarction.

Although the admission electrocardiogram (ECG) was normal, ECG changes developed early in the admission (fig 1).

Fig 1 Lead II rhythm strip on a 12 lead electrocardiogram


  • 1 What is the unifying diagnosis?

  • 2 What is the main abnormality on the electrocardiogram?

  • 3 What is the next definitive cardiac investigation?

  • 4 How should this condition be managed?


1 What is the unifying diagnosis?

Short answer

Infective endocarditis with an aortic root abscess.

Long answer

Infective endocarditis with an aortic root abscess. The two most important local complications of this condition are spread of infection, which may cause perivalvular abscess and cardiac failure through valvular insufficiency. Local spread of infection has a predilection for the weakest portion of the aortic valve annulus near the membranous septum and atrioventricular node (fig 2). This …

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