A 64-year-old man was admitted following a syncopal episode with associated cough and fever of 3-day duration. He was an active smoker and intranasal cocaine user with a remote history of pulmonary tuberculosis, hepatitis C virus (HCV) infection, and intravenous drug use. He had completed antituberculous therapy, and his HCV infection had remitted without evidence of chronic liver disease. His immunization status was unknown. His physical exam was positive for fever and a left parasternal systolic murmur without radiation. Auxiliary tests were remarkable for mild leukocytosis, azotemia and negative HIV serology. His chest X-ray was unremarkable, and ECG showed normal sinus rhythm. Streptococcus pneumoniae was isolated from 6/6 blood cultures drawn on admission and one day thereafter, with very low minimum inhibitory concentration (MIC) for penicillin (E-test 0.023 mug/mL, AB Biodisk). A transthoracic echocardiogram (TTE) demonstrated a thickened and redundant septal leaflet of the tricuspid valve suggestive of vegetation (Fig. 1) along with moderate tricuspid regurgitation, hence fulfilling modified Duke criteria for the diagnosis of infective endocarditis (IE). A single right middle lobe paracardiac infiltrate demonstrated on chest CT was deemed the possible primary infection source. Ceftriaxone 2 g IV daily was started with the ensuing resolution of fever and bacteremia within 24 h of treatment. No embolic or immunologic phenomena were noted throughout his admission. Repeat ECGs continued to show normal sinus rhythm and a follow-up TTE after seven days of antimicrobial treatment revealed a decreased size of the vegetation without signs of intracardiac complications. The patient completed 28 days of IV ceftriaxone treatment and was discharged home; he was lost to follow-up.