A 52-year-old man presented with complaints of intermittent fever associated with loss of appetite, loss of weight, and generalized malaise for a duration of 2 weeks. He also complained of shortness of breath on exertion without any bleeding manifestations or history of recurrent infections. There was no chronic cough, hemoptysis, joint pain or swelling, and rashes. The patient did not reveal urinary symptoms or history of chronic diarrhea. There were no features suggestive of auto-immune diseases and no recent use of medication before the onset of fever. There was no contact history or past history of tuberculosis. He is a general clerk in occupation and there was no close contact with animals. There were no recent dental procedures he had undergone and he maintained good oral hygiene. There was no significant travel history and history of intravenous drug use. He was a known patient with ventricular septal defect (VSD) and true dextrocardia and was not on regular follow-up due to refusal of surgical interventions. The patient was not on any long-term medications. At presentation, he was alert and not dyspneic, and mild pallor was present. His oral hygiene was good. His blood pressure was 110/56 mmHg, pulse rate 88 beats per minute, regular respiratory rate 12/min, SPO2 98%, and temperature 37 C. A pansystolic murmur was heard with evidence of dextrocardia. Mild splenomegaly was found on abdominal examination without hepatomegaly. Respiratory and neurological examination was unremarkable.
Laboratory investigations of the patient are listed in Table 1.
Electrocardiogram showed right axis deviation, inversion of all complexes (inverted P and T waves, negative QRS complexes), "global negativity," positive QRS in aVR, and absent R-wave progression (Figure 1). Two-dimensional echocardiogram revealed tricuspid valve large vegetation attached to septal leaflets of the tricuspid valve, hypermobile with a high risk of embolization, and other vegetation attached to the lateral leaflet of the tricuspid valve and also dextrocardia and restrictive VSD with a left-to-right shunt.
All three blood cultures yielded pure growth of S. acidominimus, sensitive to ampicillin, penicillin, clindamycin, and erythromycin. The organism was isolated using BACTEC  FX aerobic blood culture system by BD, and antimicrobial sensitivity tests were determined by disk diffusion using CLSI initially but ID by VITEK 2 .
The patient was diagnosed with right-sided IE and started on intravenous penicillin 4 million units every 4 hourly and he was given oral clindamycin 300 mg every 6 hourly for 7 days due to cannula site infection. Resolution of fever was observed after 48 h of initiation of antibiotic therapy. Follow-up blood culture at 72 h was negative. Significant biochemical response was observed in C-reactive protein and erythrocyte sedimentation rate after 1-week and 2-week course of antibiotic therapy, respectively. He was successfully treated for 6 weeks with a course of intravenous penicillin, and there were no complications of IE reported during the treatment. Follow-up two-dimensional echocardiogram after completion of antibiotics showed complete resolution of the vegetations.