Images in clinical medicine. Mitral-valve endocarditis

A 56-year-old man presented with severe lumbar pain, a seven-week history of fever (temperature as high as 39*C), a 10-kg weight loss, and a recent history of treatment with cephalosporins. He had a herniated IA-L5 intervertebral disk and hypertensive heart disease with a dilated left ventricle, reduced left ventricular function, and mild-to-moderate mitral regurgitation. Examination disclosed a grade 3/6 holosystolic murmur and evidence of sciatica.