A Brewing Back Pain

This Clinical Problem-Solving case details the diagnostic journey of a 67-year-old man who presented with back pain and systemic symptoms including weight loss, anemia, splenomegaly, thrombocytopenia, and a monoclonal gammopathy. Initial concerns included malignancy and autoimmune disease, but his evolving symptoms palpable purpura, a changing pansystolic murmur, and progression to heart failure pointed toward infective endocarditis. Blood cultures revealed vancomycin-resistant Lactobacillus, and transesophageal echocardiography identified a flail posterior mitral valve leaflet with vegetation. Myxomatous degeneration and histopathology confirmed infective endocarditis secondary to structural mitral valve disease. The case emphasizes atypical presentations of endocarditis and the diagnostic complexity posed by indolent organisms and overlapping autoimmune features.

This Clinical Problem-Solving case details the diagnostic journey of a 67-year-old man who presented with back pain and systemic symptoms including weight loss, anemia, splenomegaly, thrombocytopenia, and a monoclonal gammopathy. Initial concerns included malignancy and autoimmune disease, but his evolving symptoms palpable purpura, a changing pansystolic murmur, and progression to heart failure pointed toward infective endocarditis. Blood cultures revealed vancomycin-resistant Lactobacillus, and transesophageal echocardiography identified a flail posterior mitral valve leaflet with vegetation. Myxomatous degeneration and histopathology confirmed infective endocarditis secondary to structural mitral valve disease. The case emphasizes atypical presentations of endocarditis and the diagnostic complexity posed by indolent organisms and overlapping autoimmune features.