A 56 year old, right handed African-American man with past history of left knee osteoarthritis, remote intravenous drug use, remote alcoholism, and seropositivity for hepatitis C was admitted to a local hospital for fatigue, chest pain, 13.6 kg weight loss, night sweats, and vision loss. On examination, a loud systolic murmur was present. An electrocardiogram (ECG) displayed T wave alternans and a transoesophageal echocardiogram revealed severe mitral regurgitation with mitral valve vegetations, ruptured chordae tendineae, and left ventricular ejection fraction of 75%. He was diagnosed as having endocarditis and cytomegalovirus endophthalmitis, and was treated with ceftriaxone, vancomycin, ganciclovir, foscarnet, aspirin, metoprolol, lisinopril, nifedipine, and intravenous esmolol. He developed fever (39.3°C) and his mental status declined. A head computed tomography (CT) scan showed left occipital haemorrhage. His left leg became cold and pale with an ankle:brachial index of 0.4. Blood cultures grew yeast. Amphotericin B was started and he was transferred to our hospital for further care.

Upon arrival his temperature was 36.4°C, pulse was 80 beats per minute and regular, respiratory rate was 25 per minute, and blood pressure was 106/76 mm Hg on the right and 160/83 mm Hg on the left. On auscultation a II/VI holosystolic murmur over the apex and bibasilar rales were heard. His left leg was cold with pulses detectable only by Doppler. He was alert and oriented to person and place only, and …