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Transesophageal echocardiogram showing a mobile, 16x3 mm, filiform image inserted in the medial segment of the atrial aspect of the lateral leaflet of the tricuspid valve, consistent with a vegetation.

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Chest computed tomography CT Figure 2 showed multiple peripheral pulmonary nodules, suggesting septic emboli. No alterations were observed in x-rays of the shoulders and elbows.

The diagnosis of native tricuspid valve IE with no clear predisposing condition was established. The portal of entry was not precisely identified, although the left elbow skin lesion described by the patient was considered, even though there was no significant evidence of inflammation.

The endocarditis was complicated by asymptomatic pulmonary involvement, anemia, vasculitic purpura, and oligoarthritis, probably due to an immunologic mechanism. Skin biopsy was not performed since the lesions were regressing, and the synovial fluid was not studied because of the small amount.

Chest computed tomography image showing various small, bilateral, peripheral and subpleural nodules, with cavitation in some cases, suggesting septic emboli. The wedge-shaped opacities with an internal air bronchogram, in which the base is in contact with the pleura, suggest small pulmonary infarcts.

This treatment was changed to cefazolin after findings consistent with immunoallergic interstitial nephritis were observed deterioration of renal function with significant peripheral eosinophilia and eosinophiluria, all of which resolved with the change in antibiotic , although there was no histological confirmation.

Subsequent challenge study was not considered appropriate. After 6 weeks of specific intravenous antibiotic therapy, blood cultures were negative, the patient was hemodynamically stable and the joint symptoms had resolved completely, leaving no radiologic sequelae.

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