Biventricular mural vegetations without valvular involvement: an unusual presentation of Staphylococcus aureus endocarditis.

A 42-year-old intravenous drug user presented with sepsis and multiple brain and systemic emboli. Blood cultures were positive for Staphylococcus aureus. Transoesophageal echocardiography showed two masses in the left and the right ventricle. The LV mass was large (2.3x1.5cm), irregular, mobile and attached to the basal anterolateral LV segment, abutting but not involving the mitral valve. (Figure 1, Video 1). The RV mass was smaller (1.7x1.5 cm) irregular and mobile, possibly involving the subvalvular apparatus but not encroaching the tricuspid valve (Figure 2). Once commenced on antibiotics the patient improved and there were no further embolic events. Although the echocardiographic definition of vegetation includes masses on any endocardial surface1, mural endocarditis without valvular involvement is considered extremely rare2. The diagnosis is supported by the septic and embolic clinical picture but requires awareness of this uncommon entity. The present case is even more unusual in view of the biventricular mural localisation of the vegetations, a pattern that has been mentioned in only very few case reports3,4.